Insurance Business Owner Application

Insurance Business Owner Application

Applicant / Insured Information

Business Legal Name:

Date of Birth:    Social Security Number / Tax ID:

Business Phone:    Email:

Business Operations

Years in Business:    Number of Employees:    Annual Gross Revenue:

Policy Details Requested

Policy Type (select all that apply):

General Liability Property / Commercial Property Professional Liability (E&O) Workers' Compensation Business Interruption

Deductible:    Estimated Annual Premium:

Policy Effective Date Requested:    Policy Term (months):

Property & Location Details

Building Construction Type:    Total Square Footage:

Fire Protection (select all that apply): Sprinkler Fire Alarm None

Claims History

Any claims, suits, or incidents in the past 5 years?    Yes No

Coverage Options & Endorsements

Optional Endorsements (select if desired):

Cyber Liability Employee Dishonesty / Theft Data Breach Response Extended Business Interruption

Exclusions & Acknowledgment

The policy issued may contain exclusions, limitations, and conditions including, but not limited to, pollution, intentional acts, professional services exclusions, and nuclear hazard exclusions. Applicant acknowledges that the insurer may attach additional exclusions based on underwriting review. Applicant must indicate acknowledgment and acceptance below.

I have read and acknowledge potential standard exclusions and limitations.

Beneficiary Designation (if applicable)

Primary Beneficiary Name:

Relationship:    Percentage:

Contingent Beneficiary Name:

Relationship:    Percentage:

Premium Payment & Agency Information

Requested Payment Method: Annual Semi-Annual Monthly

Declarations, Representations and Authorization

By signing below, the applicant certifies that the information contained in this application is true, complete and accurate to the best of the applicant's knowledge. Applicant understands that this application forms the basis of any policy issued and that material misrepresentation, omission, or concealment of fact may result in rescission, denial of coverage, or other remedies permitted by law. Applicant authorizes the insurer and its representatives to obtain and verify underwriting, claims, credit, and loss control information from third parties and prior insurers as necessary for evaluation of this application.

Applicant acknowledges receipt of a preliminary disclosure that quotes and binding are contingent upon underwriting review and completion of any additional inspections or documentation requested. Coverage is not effective until issued in writing by the insurer.

Fraud Warning: Where applicable by law, any person who knowingly presents a false or fraudulent claim, application or statement for the purpose of obtaining insurance coverage or benefits may be guilty of a criminal act and subject to penalty under state law.

Additional Information / Comments

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