Business Insurance Quote
Please fill in the information below to receive a quote

Primary Contact First Name Last Name
Company:
Years Company has been in Business
Company Type:
Number of Owners: Gross Sales
Tax ID or EIN
Number of Employees:

Company Address:
City
: State: Zip
Phone:( Fax:( Email:
List the states you do business in if more than one
Type of Business & Description:
Please Describe Business in Detail:
Do you use sub contractors?

Coverage Information
Requested Aggregate Liabilty Limit: Occurrence Limit:
Company (not agency):
Any Losses in last 3 years?
Please describe any Losses give details and give dates

General Questions for All Businesses

1a.  IS THE APPLICANT A SUBSIDIARY OF ANOTHER ENTITY ? 

6.  DURING THE LAST FIVE YEARS (TEN IN RI), HAS ANY APPLICANT BEEN INDICTED FOR OR CONVICTED OF ANY DEGREE OF THE CRIME OF FRAUD, BRIBERY, ARSON OR ANY OTHER ARSON-RELATED CRIME IN CONNECTION WITH THIS OR ANY OTHER PROPERTY?

1b.  DOES THE APPLICANT HAVE ANY SUBSIDIARIES?
2.  IS A FORMAL SAFETY PROGRAM IN OPERATION? 7.  ANY UNCORRECTED FIRE CODE VIOLATIONS?
3.  ANY EXPOSURE TO FLAMMABLES, EXPLOSIVES, CHEMICALS?
8.  ANY BANKRUPTCIES, TAX OR CREDIT LIENS AGAINST THE APPLICANT IN THE PAST 5 YEARS?
4.  ANY POLICY OR COVERAGE DECLINED, CANCELLED OR NON-RENEWED DURING THE PRIOR 3 YEARS? 9.  HAS BUSINESS BEEN PLACED IN A TRUST?
5.  ANY PAST LOSSES OR CLAIMS RELATING TO SEXUAL ABUSE OR MOLESTATION ALLEGATIONS, DISCRIMINATION OR NEGLIGENT HIRING?

10. ANY FOREIGN OPERATIONS, FOREIGN PRODUCTS DISTRIBUTED IN USA, OR US PRODUCTS SOLD/DISTRIBUTED IN FOREIGN COUNTRIES?


11. ANY MEDICAL FACILITIES PROVIDED OR MEDICAL PROFESSIONALS EMPLOYED OR CONTRACTED?

21. SPORTING OR SOCIAL EVENTS SPONSORED?
12. ANY EXPOSURE TO RADIOACTIVE/NUCLEAR MATERIALS? 22. ANY STRUCTURAL ALTERATIONS CONTEMPLATED?
13. DO/HAVE PAST, PRESENT OR DISCONTINUED OPERATIONS INVOLVE(D) STORING, TREATING, DISCHARGING, APPLYING, DISPOSING, OR TRANSPORTING OF HAZARDOUS MATERIAL? (e.g. landfills, wastes, fuel tanks, etc) 23. ANY DEMOLITION EXPOSURE CONTEMPLATED?

24. HAS APPLICANT BEEN ACTIVE IN OR IS CURRENTLY ACTIVE IN JOINT VENTURES?

14. ANY OPERATIONS SOLD, ACQUIRED, OR DISCONTINUED IN LAST 5 YEARS?

25. DO YOU LEASE EMPLOYEES TO OR FROM OTHER EMPLOYERS?
15. MACHINERY OR EQUIPMENT LOANED OR RENTED TO OTHERS?

26. IS THERE A LABOR INTERCHANGE WITH ANY OTHER BUSINESS OR SUBSIDIARIES?

16. ANY WATERCRAFT, DOCKS, FLOATS OWNED, HIRED OR LEASED? 27. ARE DAY CARE FACILITIES OPERATED OR CONTROLLED?
17. ANY PARKING FACILITIES OWNED/RENTED?

28. HAVE ANY CRIMES OCCURRED OR BEEN ATTEMPTED ON YOUR PREMISES WITHIN THE LAST THREE YEARS?

18. IS A FEE CHARGED FOR PARKING?

29. IS THERE A FORMAL, WRITTEN SAFETY AND SECURITY POLICY IN EFFECT?

19. RECREATION FACILITIES PROVIDED?

30. DOES THE BUSINESSES' PROMOTIONAL LITERATURE MAKE ANY REPRESENTATIONS ABOUT THE SAFETY OR SECURITY OF THE PREMISES?

20. IS THERE A SWIMMING POOL ON THE PREMISES?


If you are a CONTRACTOR you must answer the following questions:

1. DOES YOUR DRAW PLANS, DESIGNS, OR SPECIFICATIONS FOR OTHERS?

4. DO YOUR SUBCONTRACTORS CARRY COVERAGES OR LIMITS LESS THAN YOURS?

2. DO ANY OPERATIONS INCLUDE BLASTING OR UTILIZE OR STORE EXPLOSIVE MATERIAL?

5. ARE SUBCONTRACTORS ALLOWED TO WORK WITHOUT PROVIDING YOU WITH A CERTIFICATE OF INSURANCE?

3. DO ANY OPERATIONS INCLUDE EXCAVATION, TUNNELING, UNDERGROUND WORK OR EARTH MOVING?

6. DOES APPLICANT LEASE EQUIPMENT TO OTHERS WITH OR WITHOUT OPERATORS? 

 

If you MANUFACTURE, RESELL or REPACKAGE PRODUCTS 

you must answer the following questions:

1. DO YOU INSTALL, SERVICE OR DEMONSTRATE PRODUCTS?

6. PRODUCTS RECALLED, DISCONTINUED, CHANGED?

2. FOREIGN PRODUCTS SOLD, DISTRIBUTED, USED AS COMPONENTS?

7. PRODUCTS OF OTHERS SOLD OR RE-PACKAGED UNDER YOUR LABEL?

3. RESEARCH AND DEVELOPMENT CONDUCTED OR NEW PRODUCTS PLANNED?

8. PRODUCTS UNDER LABEL OF OTHERS?

4. GUARANTEES, WARRANTIES, HOLD HARMLESS AGREEMENTS?

9. VENDORS COVERAGE REQUIRED?

5. PRODUCTS RELATED TO AIRCRAFT/SPACE INDUSTRY?

10. DOES ANY NAMED INSURED SELL TO OTHER NAMED INSUREDS?

Please describe your product(s) in the box to the left:

1.  How long each one has been in the market place

2.  Number of units sold last year

3.  Annual sales by product line


Please list any other information you feel is important or relevant to this quote:
 

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