Commercial Intake Form Commercial Intake Form Business Name:(Required) Complete legal business name.DBA (Doing Business As): Effective Date:(Required) MM slash DD slash YYYY What is the Effective Date for the prospective insurance policy(ies)?Quote Due Date:(Required) MM slash DD slash YYYY Contact Name:(Required) First Last Phone:(Required)Phone Type (Dropdown):(Required)CellWorkHomeReferral Contact Name Email:(Required) FEIN (Tax ID):(Required)XX-XXXXXXXBusiness 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 Mailing Address (If Different from Business Address): 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 Property Schedule(Required)Year BuiltSquare FootageOccupancy Add RemoveAddress, Construction Type, Occupancy, Protections, Exposure required. Updates:(Required)RoofElectricalPlumbingHVAC Add RemovePlease provide the year of the most recent replacement/update.Business Description:(Required)Please write a narrative describing the business being submitted for quotation. Lines of Coverage:(Required) BOP General Liability Property Commercial Auto Workers Compensation Inland Marine Umbrella Professional Liability Select AllPlease select all lines of coverage requestedFile Upload: Drop files here or Select files Max. file size: 2 MB. i.e.; Loss Runs, Statement of Values, Application(s), Dec Page(s), Experience ModGross Sales:(Required)Total anticipated Gross Sales for the next 12 monthsPayroll (Not including Excluded Officers):(Required)Additional Insured?(Required) Yes No Blanket Required? Yes No Primary and Non-Contributory? Yes No Waiver of Subrogation? Yes No Blanket Required? Yes No Work Comp Class Codes and Payrolls:(Required)Work Comp Class CodeFull-Time EmployeesPart-Time EmployeesPayroll Add Remove4-Digit Class code from NCCI. Please add a new row for another Class Code by clicking the plus (+) sign. Do You Use Subcontractors?(Required) Yes No What is the Total Cost of Subcontractors?(Required)Please provide the anticipated Total Cost paid to Subcontractors for the next 12 months. Do You Obtain Yearly Certificates from All Subcontractors? Yes No Certificates should name you as Additional Insured and show proof of Workers Compensation coverage. Property Coverage Requested?(Required) Building BPP/Inventory Business Interruption Boiler & Machinery Check all that apply. Building:(Required)BPP/Inventory:(Required)Deductible Requested:(Required)$250$500$1,000$2,500$5,000$10,000Mortgagee Required? Yes No Loss Payee Required? Yes No Mortgagee:(Required) Loss Payee:(Required) Mortgagee 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 Loss Payee 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 Driver's List:(Required) Add RemoveFirst and Last Name, Date of Birth, and Driver's License Number Required. Vehicle Schedule:(Required) Add RemoveYear, Make, Model, VIN, and Cost New Required. Physical Damage Coverage Requested?(Required) Yes No Comprehensive and Collision. Comprehensive Deductible:(Required)Full Coverage$250$500$1,000$2,500$5,000Physical Damage (Other than Collision coverage)Collision Deductible:(Required)Full Coverage$250$500$1,000$2,500$5,000Physical Damage from Collision Hired and Non-Owned Auto Requested?(Required) Yes No Auto Limits:(Required)$300,000$500,000$1,000,000Combined Single Limit (Liability, Uninsured Motorist, Underinsured Motorist, Hired and Non-Owned Auto, if Requested)Inland Marine Coverage:(Required) Scheduled Equipment Small Tools Employee Tools Leased/Rented Equipment Installation Floater Builder's Risk Select AllPlease check the box next to the exposure present. Inland Marine Deductible:(Required)$250$500$1,000$2,500$5,000Equipment Schedule:(Required)YearMakeModelSerialDescriptionValue Add RemoveYear, Make, Model, Serial Number, Description, and Value Required. Please add a new row for another Class Code by clicking the plus (+) sign.Small Tools:(Required)$2,500$5,000$10,000$25,000$50,000$100,000OtherTools with a value below $2,500. Other Small Tools Limit:(Required)Employee's Tools:(Required)$2,500$5,000$10,000$25,000$50,000$100,000OtherTools owned by your Employee's but used in the course of your business. Other Employee's Tools Limit:(Required)Leased/Rented Equipment:(Required)$2,500$5,000$10,000$25,000$50,000$100,000OtherEquipment or Tools, Leased or Rented by the Insured. Other Leased/Rented Equipment Limit:(Required)Installation Floater:(Required)$2,500$5,000$10,000$25,000$50,000$100,000OtherValue of furnishings to be installed at a customer's location. Other Installation Floater Limit:(Required)Builder's Risk Limit:(Required)Untitled
