Commercial Insurance Proposal Request

Name

This field is for validation purposes and should be left unchanged.

Commercial Business Insurance Offerings

Commercial Business Insurance Offerings*

Commercial Auto

Commercial Liability

Commercial Property

Commercial Umbrella

Workers’ Comp

Surety Bonds

Maximize Employee Benefits

Trucking

Life Science

Cannabis Business

Hospitality

Contact Information

Name*

First Last

Email*

Enter Email Confirm Email

Phone*

Business Information

Name of Business

Type of Entity

Corporation

LLC

Sole Proprietor

Business Phone

Website

Business Physical Address

Street Address Address Line 2 City State ZIP Code

Business Mailing Address

Same as Physical

Street Address Address Line 2 City State ZIP Code

Description of Operations

Commercial Auto

Vehicle(s) Information

Year

Make

Model

VIN

Driver(s)

Name

Date of Birth

License # and State

Current Insurance Carrier

Commercial Auto - Past 3 Years Claims/Tickets

Commercial Auto Documents

Please upload any pertinent documents (Current declaration pages)

Drop files here or

Accepted file types: pdf, jpg, gif, png, Max. file size: 50 MB.

Commercial Liability

Estimated Annual Revenue

Estimated Annual Employee Payroll

Occupied Square Feet

Business Property to be covered

Equipment, Inventory, Fixtures ...

Policy Effective Date Requested

MM slash DD slash YYYY

Commercial Liability Documents

Please upload any pertinent documents (Current declaration pages)

Drop files here or

Accepted file types: pdf, jpg, gif, png, Max. file size: 50 MB.

Commercial Property

Buildings

Year Built

Units

Stories

Square Footage

Laundry Room

Pool

Replacement cost of building

Upgrades Performed

Any Zinsco, Pushmatic, Federal Pacific (FPE), Stab-Lok, Challenger electric panels

Yes

(if yes the carriers won’t accept)

Current Commericial Liability Insurance Carrier

Commercial Liability Property to be covered

Equipment, Inventory, Fixtures ...

Commercial Liability Documents

Please upload any pertinent documents (Current declaration pages)

Drop files here or

Accepted file types: pdf, jpg, gif, png, Max. file size: 50 MB.

Commercial Umbrella

Commercial Umbrella Details

Please provide details about your insurance needs

Commercial Umbrella Documents

Please upload any pertinent documents (Current declaration pages)

Drop files here or

Accepted file types: pdf, jpg, gif, png, Max. file size: 50 MB.

FEIN

Employer ID #

Number of Employees

Corporate Officers

Name

Title

Excluded or Included?

Current Worker's Compensation Insurance Carrier

Any Worker's Compensation Claims in the Past 3 years?

Any Driving Exposures?

Worker's Compensation Documents

Please upload any pertinent documents (Current declaration pages)

Drop files here or

Accepted file types: pdf, jpg, gif, png, Max. file size: 50 MB.

Surety Bonds

Surety Bonds Insurance Details

Surety Bonds Documents

Please upload any pertinent documents (Current declaration pages)

Drop files here or

Accepted file types: pdf, jpg, gif, png, Max. file size: 50 MB.

Maximize Employee Benefits

Maximize Employee Benefits Details

Maximize Employee Benefits Documents

Please upload any pertinent documents (Current declaration pages)

Drop files here or

Accepted file types: pdf, jpg, gif, png, Max. file size: 50 MB.

Trucking

Trucking Insurance Details

Current Trucking Insurance Carrier

Truck(s)

Year

Make

Model

VIN

Truck Driver(s)

Name

Date of Birth

License # and State

Trucking Past 3 Years Claims/Tickets

Trucking Insurance Documents

Please upload any pertinent documents (Current declaration pages)

Drop files here or

Accepted file types: pdf, jpg, gif, png, Max. file size: 50 MB.

Life Science

Life Science Insurance Details

Please provide details about your insurance needs

Life Science Documents

Please upload any pertinent documents (Current declaration pages)

Drop files here or

Accepted file types: pdf, jpg, gif, png, Max. file size: 50 MB.

Cannabis Business

Cannabis Business Insurance Details

Please provide details about your insurance needs

Cannabis Business Insurance Documents

Please upload any pertinent documents (Current declaration pages)

Drop files here or

Accepted file types: pdf, jpg, gif, png, Max. file size: 50 MB.

Hospitality

Hospitality Insurance Details

Please provide details about your insurance needs

Hospitality Insurance Documents

Please upload any pertinent documents (Current declaration pages)

Drop files here or

Accepted file types: pdf, jpg, gif, png, Max. file size: 50 MB.

Additional information

Anything else that we should be aware of (Including any other insurance policy needs)