“Find the Right Insurance”

Zip Code:

 

 

Current Client:

 

• Yes
• No

 

 

Account Executive/Contact Referral:

 Select OneNoYes

 

 

Executive Name:

 Select OneMike MitcheomGail SeibertKeith EatonAmora GloverVeronica GonzalesJason SpitzerDiane HansenJennifer SmithCarla HenryKarren Chavez

 

 

"Risk Assessment"

Gross Revenue(before any splits):

 

 

Number of Agents:

 

 

Number of Employees:

 

 

Annual Payroll:

 

 

Number of Unit Transactions:

 

 

Dollars paid to Agents and/or Independent contractors:

 

 

 

“Property Information”

Interest in Property:

 Select OneOwner/OccupantTenant

 

Year Building was built:

 

 

Year Updated/Remodeled:

 

 

Total Square Footage:

 

 

Percentage Occupied by You:

 

 

 

Building Construction/Framing type:

 Select OneWoodBrickConcreteSteelOther Type

 

 

Describe:

 

 

 

Roofing Material:

 Select OneAsphaltComposite ShingleWood ShingleTar and GravelMembraneOther Material

 

 

Describe:

 

 

 

Electrical Wiring:

 Select OneConduitRomexAluminumOther Wiring

 

 

Describe:

 

 

 

Circuit Breaker:

 

• Yes
• No

 

Distance from fire station?

 

 

Distance from fire hydrant?

 

 

Sprinklers:

 

• Yes
• No

 

Smoke Detectors:

 

• Yes
• No

 

Central Alarm:

 

• Yes
• No

 

Building Exterior Exposure North (describe):

 

 

Building Exterior Exposure South (describe):

 

 

Building Exterior Exposure East (describe):

 

 

Building Exterior Exposure West (describe):

 

 

Additional Security/Fire Protection: (describe):

 

 

 

Additional Interest/Certificate Recipients:

 Select OneNoneYes Additional

 

 

Additional Insured Name and Address:

 

 

Loss Payee Name and Address:

 

 

Mortgage Name and Address:

 

 

LienHolder Name and Address:

 

 

 

“Business Details”

Name of Applicant:

 

 

List all D.B.A.s:

 

 

Legal Status:

 Select OneIndividualPartnershipCorporationJoint VentureS-CorpNon-ProfitLLC

 

 

Is the applicant associated with any other firm?

 Select OneAssociated NoAssociated Yes

 

 

Explain:

 

 

 

Is the applicant involved in any other business?

 Select OneOther Business NoOther Business Yes

 

 

Explain:

 

 

 

Does the applicant have multiple locations?

 Select OneMulti Locations NoMulti Locations Yes

 

 

Explain:

 

 

 

Describe Operation and Product in Detail:

 

 

Month/Year applicant was established?

 

 

 

"Policy Information"

Will this replace an existing policy:

 Select OneReplace Existing NoReplace Existing Yes

 

 

Current E&O Carrier:

 

 

Current Premium:

 

 

 

Number of claims last 5 years:

 Select OneZero1-3More than 3

 

Desired Limits of Liability:

 Select One1,000,000/1,000,0001,000,000/2,000,000(standard)2,000,000/2,000,000

 

Desired Deductible:

 Select One1,0002,5005,00010,00025,000

 

How many years has the applicant been Continuously insured?

 Select One0 years1-2 years3-4 years5 or more

 

 

Let Us Help You:

Address:

 

 

City:

 

 

State:

 Select OneALARAKAZCACOCTDCDEFLGAHIIAIDILINKSKYLAMAMDMEMIMNMOMSMTNCNDNENHNJNMNVNYOHOKORPARISCSDTNTXUTVAVIVTWAWIWVWYGUPR

 

First Name:

 

 

Last Name:

 

 

Email:

 

 

Phone Number:

 

 

Cell Phone Number:

 

 

Fax Number:

 

 

Information to Share:

 

 

 

Any information you share with us is secure. It will not be sold or reused.