Small Commercial Account Submission
Agency Name:
Contact Name:
Agency Phone:
Agency Fax:
Agency Email:
Type of Risk
Lessor's Risk
Office
Garage
Restaurant
Apartment
Retail
Service
Contractors
Technology
Other
Insured's Information
Insured's Name:
Name of Business:
Insured's Address:
City:
State:
Zip:
FEIN or SSN:
Phone Number:
Expiring Premium:
Current Carrier:
Expiration Date:
Detailed Description of the Insured's
Operations & Other Occupancies
Entity Type:
Insured Interest:
Partnership
Owner Occupant
Corporation
Lessor
Other
Tenant Only
Sole Proprietor
Years in Business:
Payroll:
Sales:
Number of Employees:
Desired Coverage Limits
Location #1
Physical Location:
County:
Protection Class:
Building Limit: (Replacement Cost)
Business Personal Property Limit:
Personal Property of Others:
General Liability Limit:
$500,000 / $1 Million
$1 Million / $2 Million
$2 Million / $4 Million
Deductible
$500
$1,000
$2,500
Other:
Construction Type:
Year Built:
Number of Stories:
Square Footage:
Roof Update:
Wiring Update:
Plumbing Update:
Heat/Air Update:
Sprinklered:
Yes
No
Fire Alarm System:
Yes
No
Burglar Alarm System:
Yes
No
Location #2
Physical Location
County:
Protection Class:
Building Limit: (Replacement Cost)
Business Personal Property Limit:
Personal Property of Others:
General Liability Limit:
$500,000 / $1 Million
$1 Million / $2 Million
$2 Million / $4 Million
Deductible
$500
$1,000
$2,500
Other:
Construction Type:
Year Built:
Number of Stories:
Square Footage:
Roof Update:
Wiring Update:
Plumbing Update:
Heat/Air Update
Sprinklered:
Yes
No
Fire Alarm System:
Yes
No
Burglar Alarm System:
Yes
No
# of Additional Insured:
Optional Lines available subject to eligibility:
Work Comp
Business Auto
Umbrella
EPLI
You may be contacted by a commercial
underwriter for additional information
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