Your Company
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Your Protection
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Your Company History

What date did your business begin under current ownership?

How many years experience do you have in the industry?

EMPLOYEES

How many total people work in your business?(total staff, including yourself, owners, officers, employees, and contractors)

How is your business registered?

Is your company filed as a corporation?


Is your company filed as a non-profit?


ANNUAL PAYROLL

What is the annual payroll for owners and officers? (excluding subcontractors)


SUBCONTRACTING WORK TO OTHERS


Does any of your business involve subcontracting work to others?


How many independent contractors do you have?


ABOUT YOUR BUSINESS

In a few sentences, describe your business and key business operations.

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Your Information

Your first name

Your last name


Owner first name

Owner last name

Contact Phone Number

Email

What date would you like your coverage to start?

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Your Services

Since you are new in business please indicate services which you are provided :

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Your Business Details

Number of years the business owner has been in this field:


Do you have a website?


Website Name:


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Your Insurance History

Have you had any active insurance policies within the last 12 months?


Claims History

Has your company had any General Liability, Property or Worker's Compensation claims in the past 5 years?


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Your Locations

Is your business based in your home?


Primary business address
We must have a physical address to provide a quote (not a P.O. Box)






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Optional Coverages

Auto Liability

Do you have any vehicles commercially owned/titled to your business?


Do you want your quote to include coverage for Hired/Non-Owned Auto Liability?


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Insurance Fraud Warning


NEW MEXICO APPLICANTS: ANY PERSON WHO KNOWINGLY PRESENTS A FALSE OR FRAUDULENT CLAIM FOR PAYMENT OF A LOSS OR BENEFIT OR KNOWINGLY PRESENTS FALSE INFORMATION IN AN APPLICATION FOR INSURANCE IS GUILTY OF A CRIME AND MAY BE SUBJECT TO CIVIL FINES AND CRIMINAL PENALTIES.

NEW YORK APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY MATERIAL FACT THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL BE ALSO SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE STATED VALUE OF THE CLAIM FOR EACH SUCH VIOLATION.

OHIO APPLICANTS: ANY PERSON WHO, WITH INTENT TO DEFRAUD OR KNOWING THAT HE IS FACILITATING A FRAUD AGAINST AN INSURER, SUBMITS AN APPLICATION OR FILES A CLAIM CONTAINING A FALSE OR DECEPTIVE STATEMENT IS GUILTY OF INSURANCE FRAUD.

OKLAHOMA APPLICANTS: WARNING: ANY PERSON WHO KNOWINGLY, AND WITH INTENT TO INJURE, DEFRAUD OR DECEIVE ANY INSURER, MAKES ANY CLAIM FOR THE PROCEEDS OF AN INSURANCE POLICY CONTAINING ANY FALSE, INCOMPLETE OR MISLEADING INFORMATION IS GUILTY OF A FELONY.

PENNSYLVANIA APPLICANTS: ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR INSURANCE OR STATEMENT OF CLAIM CONTAINING ANY MATERIALLY FALSE INFORMATION OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME AND SUBJECTS SUCH PERSON TO CRIMINAL AND CIVIL PENALTIES.
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