• BusinessInformation

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  • Contact/ OwnerInformation

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  • GeneralInformation

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  • PolicyInformation

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  • ProductsOperations

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  • Location/ OfficeInformation

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  • AdditionalInformation

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  • CoveragesDetails

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GENERAL/LIABILITY/PROPERTY INSURANCE Commercial Auto Workers Compensation

Business Information

Nature Of Business

Policy Information

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Contact/Owner Information

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General Information

1a. Is The Applicant A Subsidiary Of Another Entity ?

1b. Does The Applicant Have Any Subsidiaries?

2. Is A Formal Safety Program In Operation?

3. Any Exposure To Flammables, Explosives, Chemicals?

4. Any Other Insurance With This Company? (list Policy Numbers)

5. Any Policy Or Coverage Declined, Cancelled Or Non-renewed During The Prior Three (3) Years For Any Premises Or Operations? (Missouri Applicants - Do not answer this question)

6. Any Past Losses Or Claims Relating To Sexual Abuse Or Molestation Allegations, Discrimination Or Negligent Hiring?

7. 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? (In RI, this question must be answered by any applicant for property insurance. Failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one year of imprisonment)

8. Any Uncorrected Fire And/or Safety Code Violations?

9. Has Applicant Had A Foreclosure, Repossession, Bankruptcy Or Filed For Bankruptcy During The Last Five (5) Years?

10. Has Applicant Had A Judgement Or Lien During The Last Five (5) Years?

11. Has Business Been Placed In A Trust?

12. Any Foreign Operations, Foreign Products Distributed In Usa, Or Us Products Sold / Distributed In Foreign Countries?

13. Does Applicant Have Other Business Ventures For Which Coverage Is Not Requested?

14. Does Applicant Own / Lease / Operate Any Drones?

15. Does Applicant Hire Others To Operate Drones? (if "yes", Describe Use)

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Existing Policy Information

Currently Insured

Loss History

Loss history(do you have losses? If yes how many losses since the beginning of the business, thats it)

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Products/Completed Operations

1. Does Applicant Install, Service Or Demonstrate Products?

2. Foreign Products Sold, Distributed, Used As Components?

3. Research And Development Conducted Or New Products Planned?

4. Guarantees, Warranties, Hold Harmless Agreements?

5. Products Related To Aircraft/space Industry?

6. Products Recalled, Discontinued, Changed?

7. Products Of Others Sold Or Re-packaged Under Applicant Label?

8. Products Under Label Of Others?

9. Vendors Coverage Required?

10. Does Any Named Insured Sell To Other Named Insureds?

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Location/Office Information

Location/Office Information

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Commercial General Information

1. Any Medical Facilities Provided Or Medical Professionals Employed Or Contracted?

2. Any Exposure To Radioactive/Nuclear Materials?

3. 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)

4. Any Operations Sold, Acquired, Or Discontinued In Last Five (5) Years?

5. Do You Rent Or Loan Equipment To Others?

6. Any Watercraft, Docks, Floats Owned, Hired Or Leased?

7. Any Parking Facilities Owned/rented?

8. Is A Fee Charged For Parking?

9. Recreation Facilities Provided?

10. Are There Any Lodging Operations Including Apartments?

11. Is There A Swimming Pool On Premises? (Check all that apply)

12. Are Social Events Sponsored?

13. Are Athletic Teams Sponsored?

14. Any Structural Alterations Contemplated?

15. Any Demolition Exposure Contemplated?

16. Has Applicant Been Active In Or Is Currently Active In Joint Ventures?

17. Do You Lease Employees To Or From Other Employers?

18. Is There A Labor Interchange With Any Other Business Or Subsidiaries?

19. Are Day Care Facilities Operated Or Controlled?

20. Have Any Crimes Occurred Or Been Attempted On Your Premises Within The Last Three (3) Years?

21. Is There A Formal, Written Safety And Security Policy In Effect?

22. Does The Businesses' Promotional Literature Make Any Representations About The Safety Or Security Of The Premises?

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Coverage Details

What coverage are you looking for?

Break down of coverage

Liability Only

  • $15,000 per person
  • $30,000 per accident
  • $10,000 property damage
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Workers Compensation General Information

1. Does Applicant Own, Operate Or Lease Aircraft / Watercraft?

2. 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)

3. Any Work Performed Underground Or Above 15 Feet?

4. Any Work Performed On Barges, Vessels, Docks, Bridge Over Water?

5. Is Applicant Engaged In Any Other Type Of Business?

6. Are Sub-contractors Used? (if "yes", Give % Of Work Subcontracted)

7. Any Work Sublet Without Certificates Of Insurance? (if "yes", Payroll For This Work Must Be Included In The State Rating Worksheet On Page 2)

8. Is A Written Safety Program In Operation?

9. Any Group Transportation Provided?

10. Any Employees Under 16 Or Over 60 Years Of Age?

11. Any Seasonal Employees?

12. Is There Any Volunteer Or Donated Labor? (if "yes", Please Specify)

13. Any Employees With Physical Handicaps?

14. Do Employees Travel Out Of State? (if "yes", Indicate State(s) Of Travel And Frequency)

15. Are Athletic Teams Sponsored?

16. Are Physicals Required After Offers Of Employment Are Made?

17. Any Other Insurance With This Insurer?

18. Any Prior Coverage Declined / Cancelled / Non-renewed In The Last Three (3) Years? (missouri Applicants - Do Not Answer This Question)

19. Are Employee Health Plans Provided?

20. Do Any Employees Perform Work For Other Businesses Or Subsidiaries?

21. Do You Lease Employees To Or From Other Employers?

22. Do Any Employees Predominantly Work At Home?

23. Any Tax Liens Or Bankruptcy Within The Last Five (5) Years?

24. Any Undisputed And Unpaid Workers Compensation Premium Due From You Or Any Commonly Managed Or Owned Enterprises?

Supplemental Information

1. Has There Been Previous Workers Compensation Coverage

2. Is There Any Unpaid Workers Compensation Premium Due Or In Dispute From You Or Any Commonly Managed Or Owned Enterprises?

3. Year Applicant's Business Began

4. Has There Been A Name Change, Consolidation, Merger, Acquisition, Sale, Purchase Or Transfer Of Assets Or ClaOwnership Change During The Past Five (5) Years?

5. Is Applicant Related Through Common Management Or Ownership To Any Entity Not Listed On The Acord 130 Form, Whether Coverage Is Required Or Not?

6. Do You Lease Workers From A Professional Employer Organization (PEO)?

7. Do You Lease Workers To A Client Company?

8. To Cover The Leased Workers?

9. Do You Provide Temporary Arrangement Services To Other Employers?

10. Do You Have A Franchise Or Licensing Agreement?

11. Is Coverage Requested For A Sports Team?

12. Do Trucking Classifications Apply? If Yes, Complete Questions 13 - 20.

13. Do You Or Your Employees Regularly Operate From A Base Terminal(s) Which Is (are) Used To Load, Unload, Store Or Transfer Freight?

14. Can Each Driver's State Of Majority Driving Time Be Established Through Verifiable Records Or Logs?

15. Please Provide A List Of All Drivers / Helpers And Their State Of Residence

16. What Type(s) Of Goods Are Being Hauled? (e.g., Coal, Dry Goods, Explosives, Scaffolding, Water / Waste Fluids From Oil Field Sites, Etc.)

17. Do You Own These Goods?

18. Is Applicant Under Exclusive Contract With Any Retail Store(s)?

19. Is Applicant Under Exclusive Contract With Any Postal Service?

20. Within What Mile Radius Is Hauling Done?

21. Have You Received Any Offers Of Voluntary Coverage?

22. Indicate The Number Of Insurance Companies Which Have Refused The Applicant Coverage In The Last 60 Days (or In Accordance With State Specific Guidelines)

23. Is The Premium Financed Through A Third Party Premium Finance Company? If Yes, A Copy Of The Agreement Must Be Provided.

24. In Applicable Jurisdictions On Qualifying Risks, Is The Loss Sensitive Rating Program (LSRP) Contingency Deposit Being Paid In Full At This Time?

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Business Owners Information

1. 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)

2. Are Athletic Teams Sponsored?

3. Are Sub Contractors Allowed To Work Without Providing A Certificate Of Insurance? If Not, Who Checks Certificates?

4. 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? (in Ri, Failure To Disclose The Existence Of An Arson Conviction Is A Misdemeanor Punishable By A Sentence Of Up To One Year Of Imprisonment).?

5. Any Policy Or Coverage Declined, Cancelled Or Non-renewed During The Prior 3 Years? (not Applicable In Mo)

6. Do You Lease Employees To Or From Other Employers?

7. Any Workers Compensation Carried?

8. Do You Own Or Operate Any Other Business?

9. Any Other Insurance With This Company? (list Policy Numbers)

10. Are You Involved In Manufacturing, Mixing, Relabeling Or Repackaging Of Products?

11. Do You Rent Or Loan Equipment To Others?

12. Has Applicant Had A Foreclosure, Repossession, Bankruptcy, Judgement Or Lien During The Past Five (5) Years?

13. Any Exposure To Flammables, Explosives Or Chemicals?

14. Any Catastrophe Exposure?

15. Any Past Losses Or Claims Relating To Sexual Abuse Or Molestation Allegations, Discrimination Or Negligent Hiring?

16. Any Uncorrected Fire Code Violations?

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Driver Information

Driver Information

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Business Commercial General Information

1. With The Exception Of Any Encumbrances, Are Any Vehicles For Which Insurance Is Requested Not Solely Owned By And Registered To The Applicant?

2. Do Over 50% Of The Employees Use Their Autos In The Business?

3. Is There A Vehicle Maintenance Program In Operation?

4. Are Any Vehicles Leased To Others?

5. Any Car Modified / Special Equipment? (include Customized Vans / Pickups)

6. Are Icc (interstate Commerce Commission), Puc (public Utility Commission) Or Other Filings Required?

7. Do Operations Involve Transporting Hazardous Material?

8. Any Hold Harmless Agreements?

9. Any Vehicles Used By Family Members? If So, Identify.

10. Does The Applicant Obtain Mvr (motor Vehicle Record) Verifications?

11. Does The Applicant Have A Specific Driver Recruiting Method?

12. Are Any Drivers Not Covered By Workers Compensation?

13. Any Vehicles Owned But Not Scheduled On This Application?

14. Any Drivers With Convictions For Moving Traffic Violations?
Applicable Only In Kansas: Under Kansas Law, The Following Traffic Violations Are Not Required To Be Reported To Insurers:
1. A speeding violation of up to six (6) miles per hour (mph) that occurs in an area with a maximum posted speed limit from 30 mph through 54 mph, or
2. A speeding violation of up to ten (10) miles per hour (mph) that occurs in an area with a maximum posted speed limit from 55 mph through 75 mph.

15. Has Agent Inspected Vehicles?

16. Are All Vehicles To Be Included In This Policy Part Of A Fleet?

17. Do You Have Electronic Monitoring Devices That Record And Transmit Data In Any Of Your Vehicles?

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Vehicle Description

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