BOP and Commercial Quote Form 1 Applicant Info 2 Premises Info 3 Nature of Business Info 4 General Info 5 Prior Carrier Info 6 Coverage Info First Name * Last Name * Phone Number * Personal Number Email Address * Mailing Address * Website Address Legal Entity *CorporationIndividualJoint VentureLLCNon-Profit OrganizationPartnershipSubchapter(s) CorporationTrustOther Number of Members and Managers: Please SpecifyIf you know GL Code (Optional) SIC (Optional) NAICS (Optional) FEIN (Optional) 1 Applicant Info 2 Premises Info 3 Nature of Business Info 4 General Info 5 Prior Carrier Info 6 Coverage Info Business Address: * State * City * Zip Code *Building Type of Occupancy: Number of Stories * Are you the:OwnerTenant How big is the building: Total Building Occupancy---less than 5%10%25%50%75100% Square footage of your premises Year Built Is your operation habitational? (Habitational Only: Apartments, Condos, Hotels, and Motels)*NoYes Number of Units * Number of Swimming Pool(s): * Select all that applyApproved Fence (Auto Lock)Limited AccessDiving BoardSlideAbove GroundIn-GroundLifeGuard Has the building been renovated?NoYes Electrical Percentage of Renovation Year Renovated Plumbing Percentage of Renovation Year Renovated Heating Percentage of Renovation Year Renovated Roof Percentage of Renovation Year Renovated Construction Type---Frame StuccoJoisted Masonry (1 or 2 stories Concrete Block with Wood Frame)Masonry (Brick/ Stone)Fire Resistive (Concrete with Multiple Stories)Other Please Specify: Type of Alarm---Local BurglaryLocal Burglary and FireCentral BurglaryCentral Burglary and FireNone Is your building fully sprinklered? NoYes Please choose the percentage of the building protected by fire sprinkler:10%30%50%70%100% Any Area Leased to Others?NoYes Square footage leased to other? Add information About the Area(s) Leased to Others if needed: 1 Applicant Info 2 Premises Info 3 Nature of Business Info 4 General Info 5 Prior Carrier Info 6 Coverage Info Select your Primary Business Category below: *---Apartment BuildingBuilding Owner other than Habitational (Lessor’s Risk)Condominium Association (HOA)Hotel/MotelContractorInstitutionalManufacturingOfficeRestaurantRetailServiceWholesaleOther Please Specify Business Type: *---ActuaryAgriculture/Forestry/FishingAir Traffic Controller AirportAnalystArchitectArt/Design/MediaBanking/Finance/Real EstateBusiness/Sales/OfficeCartographer ComptrollerCertified Public AccountantClinical Data CoordinatorConservationistConstruction/Energy TradesControllerCuratorDrafterEconomistEducation/LibraryEngineer/Architect/Science/MathEpidemiologistExecutive/DirectorFinancial Analyst/AuditorFirefighterGeographerGovernment/MilitaryGraphic DesignerHistorianHomemakerIdentification Badge/ Business Card AccountantIndustrial Hygienist InspectorInformation TechnologyInsuranceInterpreterLaboratory AssistantLegal/Law Enforcement/SecurityMaintenance/Repair/HousekeepingManagement AmbassadorManager- ProjectManager- R&DManufacturing/ProductionMedical/Social Services/ReligionMedical DirectorParamedic/ EMT GroupPilotPlannerPostmasterRange EcologistRegistrarResearch Program DirectorResearcherRestaurant/Hotel ServicesSanitarianSchool TeacherSociologistSports/RecreationState ExaminerStudentSurveyor/MapmakerTax ExaminerTechnical Staff ManagerTechnicianTherapistToxicologistTraining SpecialistTranslatorTravel/Transportation/WarehousingTreasurerTreasury AgentOther Please Specify Number of Full Time Employees * Number of Part Time Employees * Annual Sales * Annual Payroll * Year Business Started Installation, Service, OR Repair Work Percentage: Describe Your Business 1 Applicant Info 2 Premises Info 3 Nature of Business Info 4 General 5 Prior Carrier Info 6 Coverage Info Do you have any subsidiaries? YesNo Subsidiary Company Name: Percentage Owned: Relationship Description: Is a formal safety program in operation? YesNo Select all that apply: Safety ManualSafety PositionMonthly MeetingsOSHA Any exposure to flammables, explosives, and chemicals? YesNo Any policy or coverage declined, canceled, or non-renewed during the last three years for any premises or operations? YesNo Select that apply:Non-PaymentNon-RenewalAgent No Longer Represents CarrierUnderwritingCondition Corrected Describe: Any past losses or claims relating to sexual abuse or molestation allegations, discrimination, or negligent hiring? YesNo During the last five years, has any applicant ever 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? YesNo Have you had a foreclosure, repossession, bankruptcy, or filed for bankruptcy during the last five years? YesNo Occur Date: Resolve Date: Explanation: Has business been placed in a trust? YesNo Name of Trust: Any foreign operations, foreign products disturbed in the USA, or US Products Sold/Distributed in foreign countries? YesNo Do you have other business ventures for which coverage is not requested? YesNo Do you own/lease/operate any drones? YesNo Please describe: Do you hire others to operate drones? YesNo Please describe: 1 Applicant Info 2 Premises Info 3 Nature of Business Info 4 General Info 5 Prior Carrier Info 6 Coverage Info Number of years you have been insured0123+ Name of Prior Carrier *---TravelersHartfordFarmersState FarmAll StateChubb Corp.CNAFireman’s FundGaurdAIGCIGAllied/Nationwide InsuranceACELloydsOther Please Specify * Have you had any losses in the last three years?YesNo Loss #1 Date of Loss Type of Loss---FireLiabilityWaterVandalismTheftOther Please specify Amount Paid Subrogation---YesNo Claim Open---YesNoAdd another loss history Loss #2 Date of Loss Type of Loss---FireLiabilityWaterVandalismTheftOther Please specify Amount Paid Subrogation---YesNo Claim Open---YesNoAdd another loss history Loss #3 Date of Loss Type of Loss---FireLiabilityWaterVandalismTheftOther Please specify Amount Paid Subrogation---YesNo Claim Open---YesNo 1 Applicant Info 2 Premises Info 3 Nature of Business Info 4 General Info 5 Prior Carrier Info 6 Coverage Info Property Coverage Building Limit (Sq ft.*Cost per Sq ft.) Deductible ---$500$1000$2500$5000$10000Other Please Specify Business Personal Property: Actual Loss Sustained:---12 months24 monthsOther Building Ordinance Personal Property of Others (if any): Earthquake YesNo Flood YesNo Equipment Breakdown YesNo Building Ordinance YesNo Building Ordinance---10%20%50%100%Liability Coverage Occurrence/Aggregate---$1 million / $2 million$2 million / $4 million Product Liability (Same as Aggregate Limit) ---$1 million$2 million$4 million Liquor Liability (If Applicable) YesNo Annual Liquor Sales: * Classification: *---Beer and WineFull Hired/Non-Owned Auto YesNo Garage Keepers Liability (Applicable for Auto Related Businesses) Are you interested in other additional policies? Workers’ Compensation YesNo Professional Liability / E&O YesNo Employment Practice Liability (EPLI) YesNo Employee Benefits Liability YesNo Deductible Per Claim: Number of Employees Covered by Employee Benefits Plan Retroactive Date Directors & Officers Liability YesNo Commercial Umbrella YesNo Amount---$1 million$2 million$5 millionOther Please specify Earthquake YesNo Commercial Auto YesNo Data Breaches YesNo I Accept the Privacy Policy & Terms & Conditions
