Commercial

Applicant Information
Name
Address
City
Zip/Postal Code
Telephone
Email Address

Business Type
Number of Members and Managers  

Inspection Information
Contact
Telephone


Premises Information


Location 1
Address
City
Zip/Postal Code
Year Built Number of Employees
Annual Revenues
City Limits
Interest

Location 2
Address
City
Zip/Postal Code
Year Built Number of Employees
Annual Revenues
City Limits
Interest

Location 3
Address
City
Zip/Postal Code
Year Built Number of Employees
Annual Revenues
City Limits
Interest

Location 4
Address
City
Zip/Postal Code
Year Built Number of Employees
Annual Revenues
City Limits
Interest


Please describe operations and any additional locations
Indicate Sections
Proposed Effective Date


General Information
Is the applicant a subsidiary of another entity?
If "yes", please explain
Does the applicant have any subsidiaries?
If "yes", please explain
Is a formal safety program in operation?
If "yes", please explain
Any exposure to flammables, explosives, chemicals?
If "yes", please explain
Any catastrophe exposure?
If "yes", please explain
Any other isurance witht his company or being submitted?
If "yes", please explain
Any policy or coverage declined, cancelled or non-renewed during the prior three (3) years? not applicable in MO
If "yes", please explain
Any past losses or claims relating to sexual abuse or molestation allegations, discrimination or negligent hiring?
If "yes", please explain
During the last five years (ten in RI), has any applicant 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?
 In RI, this question must be answered by any applicant for property insurance. Failure to disclose the existance of an arson
conviction is a misdemeanor punishable by a sentence of up to one year imprisonment.
If "yes", please explain
Any uncorrected fire code violations?
If "yes", please explain
Any bankruptcies, tax or credit liens against the applicant in the past five (5) years?
If "yes", please explain
Has business been placed in a trust?
If "yes", please name the trust
Any foreign operations, foreign products distributed in USA or US products sold/distributed in foreign countries?
If "yes", please attach ACORD 815 for Liability Exposure and/or
ACORD 816 for Property Exposure


Any Losses?
if Yes, please explain
Disclaimer: The request will not become effective until after you have been contacted by one of our agents. Check this box to confirm.

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