General Information - Business Owners Policy (Commercial Business Policy)

Name of Business

                                                                    Year Est.                                                   Federal Identification Number   -  

Address               City                State AL AK AR AZ CA CO CT DE FL GA HI IO ID IN IL KA KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OR OK PA RI SC SD TN TX UT VA VT WA WI WV WY      Zip

Business Phone#            -         Business Fax # Email Address   Website

Contact Name                Best Time to Contact Before 9:00am EST 9:00am - 11:00am EST 11:00am - 1:00pm EST 1:00pm - 3:00pm EST 3:00pm - 5:00pm EST After 5:00pm EST                 Type of Business

Description of Operations for Business Owners Policy (Please give a complete description including if business is done in Tampa, Orlando, Miami, Sarasota, Naples, Port Charlotte, Fort Myers, or any other city):

Prior Policy Information (If new Business, just type "new" in for prior carrier)

Prior Carrier (Type "None" if  no prior in last 18 months)    Expiration Date   How Many Years of Continual Coverage New Business Less than a Year 1 Year 2 - 3 years 4 - 5 Years 5 - 10 years 10 or More Years

                        Was Policy Cancelled or Non Renewed        No Yes                Has your Company Ever Had A Claim (if yes; please describe loss(es) below)  No Yes                                                                             Please list as much about the claim as possible, including dates, names, and costs of injury. This will save us time while we are waiting  for your loss runs from your prior or current insurance carrier.

Prior General Aggregate Liability Limits or Limit Requested   $600,000 / $300,000 $1,000,000 / $500,000 $2,000,000 / $1,000,000 $3,000,000 / $2,000,000 $5,000,000 $10,000,000 $15,000,000 $25,000,000 Over $25 Million         Prior Carrier Deductible or Deductible Requested   $1000 / $1,000 Wind $1,000 / 2% Wind $2,500 / 2% Wind $5,000 / $5,000 Wind $5,000 / 2% Wind $1,000 / 3% Wind $2,500 / 3% Wind $5,000 / 3% Wind $1,000 / 5% Wind $2,500 / 5% Wind $5,000 / 5% Wind $10,000 / 5% Wind

Commercial General Liability

What are your Total Gross Receipts per Year  

General Aggregate Liability Limits     $600,000 / $300,000 $1,000,000 / $500,000 $2,000,000 / $1,000,000 $3,000,000 / $2,000,000 $5,000,000 $10,000,000 $15,000,000 $25,000,000 Over $25 Million

Do you Handle Hazardous Materials No Yes

Do you make Written Guarantees or Warrantees No Yes   

Have you ever claimed bankruptcy No Yes

Do you have Sub-Contractors  No Yes

If Yes, Do you make your Sub-Contractors carry the same Liability Limits  No Yes

Do you require Certificates of Insurance from all Sub-Contractors  No Yes

Property Coverage

How Many Buildings or locations are to be insured 1 2 3 4 5 6 7 8 9 10 or More

Value of the Property to be Insured (Total of all buildings to be insured ; if you rent or lease, type in "Lease".)

Value of Contents to be Insured (This should include: Furniture, Fixtures, Equipment, etc...)  

Square Feet of Buildings  

Are You in a Flood Zone No Yes

Are any of the buildings to be Insured on Piers, Pilings, Wharfs, or over water No Yes

Employee Information

How Many Employees does your company have  

What your Total Annual Payroll for Labor  

Do you want to cover your employee's payroll in the event of Business Interruption No Yes

Do you ant coverage for Business Income Loss in the event of Business Interruption No Yes

If Yes, What is your gross income monthly

How long do you want the payments paid for 1 Month 2 Months 3 Months 4 Months 5 Months 6 Months 1 Year Total Restoration Period

Elimination Period (Length of time before you want payments to start. The Longer the less expensive the premium.) 1 Month 2 Months 3 Months 4 Months 5 Months 6 Months 1 Year Total Restoration Period