All fields marked * are required. A supplemental application may be required depending on coverage type.

1 Business Information

Basic identifying details about the business.

Legal Business Name *

DBA (Doing Business As) — if different

Business Address *

Mailing Address — if different from above

Year Business Started *

Years in Operation *

Primary Contact Name *

Title / Role

Phone *

Email *

2 Entity Type

Select the legal structure of the business.

Business Entity Type *

If "Other," describe entity structure

FEIN / EIN (Federal Tax ID) — if applicable

Used for policy issuance. Not required at this stage but helpful.

3 Industry & Classification

Helps us find the right coverage class and markets for you.

Industry / Type of Business *

SIC Code — if known

4-digit Standard Industrial Classification code

NAICS Code — if known

6-digit North American Industry Classification code

Description of Operations *

Describe what the business actually does day-to-day. Be specific — not just the category. This is the most important field for accurate quoting.

Do you perform any work at heights, underground, or with hazardous materials?

Yes No

If yes, describe

4 Revenue & Payroll

Prior year actuals preferred. Estimates are acceptable if actuals are unavailable.

Annual Gross Revenue *

Most recent completed fiscal year

Projected Revenue (Current Year)

Annual Payroll *

Total wages paid to all employees

Owner's Salary / Draw

Included or excluded from payroll above?

Do you have subcontractors? *

Yes No

Annual Subcontractor Cost — if yes

5 Employees

Headcount affects both liability and workers' comp eligibility.

Total Number of Employees *

Include part-time and seasonal

Full-Time Employees

Part-Time Employees

Seasonal / Temporary Employees

Do employees drive for business purposes? *

Yes No

If yes, do they drive company vehicles or personal vehicles?

6 Prior Losses / Claims History

List all claims for the past 5 years. Include open, closed, and pending. Carriers will verify — honesty here protects you.

Have you had any claims in the last 5 years? *

Yes No

If yes, describe each claim below

Include: year, type of claim (GL, property, auto, WC), amount paid or reserved, and whether it is open or closed.

Year	Type	Amount Paid / Reserved	Open or Closed

No claims in the past 5 years — confirm with checkbox

Have you ever had a policy canceled or non-renewed by a carrier? *

Yes No

If yes, explain

7 Existing Coverage

Complete this section if you currently have a policy and are looking to replace or supplement it.

Do you currently have business insurance? *

Yes No Coverage lapsed

Current Carrier — if yes

Policy Expiration Date

Type(s) of Coverage Currently Carried

Check all that apply

General Liability (GL) Commercial Property Business Owner's Policy (BOP) Commercial Auto Workers' Compensation Professional Liability / E&O Umbrella / Excess Other

Current GL Limit

Annual Premium Currently Paying

Reason for Shopping / Switching

Additional Notes

Anything else we should know before we start quoting?