CommentsThis field is for validation purposes and should be left unchanged.Applicant InformationApplicant Entity Type:(Required) Individual Partnership Corporation LLC Joint Venture Other Applicant Name:(Required)Applicant’s Full Name:(Required) First Last Applicant's Company Name:(Required)Owner’s Full Name:(Required) First Last Business Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is business address the same as mailing address?(Required) Yes No Mailing Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number(Required)FaxEmail(Required) Website FEIN (Tax ID #):(Required)Does the applicant have a DBA (Doing Business As) name:In what year did the applicant start operations?(Required)Please describe the applicant's day-to-day business operations:(Required)Main area of practice, type of services provided, products, etc. - Please be detailedAre there any locations or business interests that are owned by the applicant but not shown on the application?(Required) Yes No If so, please describe:(Required)Are there high-valued goods, including merchandise at your location?(Required) Yes No If yes, what is the approximate value of your inventory?(Required)What is the value of your business personal property? (BPP are all your furniture, computers, printers, etc. Basically, anything you will take with you if you move)(Required)Annual Gross Revenue(Required)Contractor License(Required)State(s) / Area of Operation(Required)Licensed for Business in State(s):(Required)Existing Insurance PoliciesPlease provide details of your existing liability policies that the umbrella policy will extend coverage over.General Liability InsuranceInsurerPolicy NumberExpiration DateLiability Limit Add RemoveCommercial Auto Liability InsuranceInsurerPolicy NumberExpiration DateLiability Limit Add RemoveEmployer’s Liability (Workers’ Compensation)InsurerPolicy NumberExpiration DateLiability Limit Add RemoveProfessional Liability (If Applicable)InsurerPolicy NumberExpiration DateLiability Limit Add RemoveOther Policies (Cyber Liability, Directors & Officers, etc.)Coverage TypeInsurerPolicy NumberExpiration DateLiability Limit Add RemoveCoverage & Business OperationsRequested Umbrella Liability Limit:(Required) $1 Million $2 Million $5 Million Other What are your primary reasons for obtaining commercial umbrella coverage? (Check all that apply)(Required) Contractual Requirements Protection from Large Lawsuits Asset Protection Industry Regulations Other Other (please describe):(Required)Have you had any claims exceeding primary policy limits in the past five years?(Required) Yes No If yes, please provide details:(Required)Does the applicant own or operate any of the following? (Check all that apply)(Required) Heavy machinery or industrial equipment Fleet of vehicles (more than five) Aircraft, watercraft, or drones Warehouses, factories, or high-risk locations Products with potential safety hazards Other exposures Other exposures (please specify):(Required)Do you subcontract work to others?(Required) Yes No If yes, what is your estimated annual subcontractor cost?(Required)Are subcontractors required to carry liability insurance?(Required) Yes No Do you have any hazardous exposures (e.g., chemicals, heavy machinery, explosives)?(Required) Yes No Do you host large public events?(Required) Yes No If yes, estimated annual attendance(Required)Do you have company-owned vehicles?(Required) Yes No If yes, number of vehicles(Required)Types of vehicles used:(Required) Passenger Trucks Trailers Other Auto Schedule(Required)MakeModelYearCost NewWeight UseRadius Use Add RemoveClaims & Loss HistoryHave you had any liability claims in the past five years?(Required) Yes No If yes, provide details including date, amount paid, and type of claim:(Required)Have you had any auto liability claims over $50,000 in the past five years?(Required) Yes No If yes, provide details:(Required)Have you had any workers' compensation or employer liability claims over $100,000 in the past five years?(Required) Yes No If yes, provide details(Required)Have you had any lawsuits or settlements over $500,000 in the past five years?(Required) Yes No If yes, provide details(Required)Risk Management & Safety MeasuresDo you have a formal risk management program in place?(Required) Yes No Do you conduct employee safety training regularly?(Required) Yes No Does the applicant have security measures in place at business locations?(Required) Yes No If yes, provide details(Required)Has the applicant been subject to any lawsuits in the past five years?(Required) Yes No If yes, provide details(Required)Insurance History & Claims InformationDo you currently have a commercial umbrella insurance policy?(Required) Yes No If yes, name of current insurer:(Required)Policy expiration date:(Required) MM slash DD slash YYYY Current coverage limit:(Required)Annual Premium:(Required)Have you had any liability claims or lawsuits in the past five years?(Required) Yes No If yes, please provide details (date, type of claim, amount paid):(Required)Has the applicant ever had insurance coverage canceled or non-renewed?(Required) Yes No If yes, please explain:(Required)Additional Comments or Special Considerations(Please provide any other relevant information that may impact your insurance coverage needs.) 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