Business Owner Form

Page 1 of 2

Business Owners Form

Named Insured

First

Last

Street*

Street

City*

State*

Zip Code*

Zip Code

Contact Name (If different from insured)

First

Last

Phone Number*

Fax Number

Location Same As Address?*

Yes

Email address*

Current / Previous Carrier Company

Prior Premium*

Prior Policy Number*

Remarks/Loss History*

Tax ID *

Policy Information

Occurrence Limit

Legal Entity

Fire Legal Limit

General Aggregate

Medical Expense Amount

Product/Completed Operations

Building Details

Decription of Occupancy*

Type Of Occupancy*

Class Code*

Class Description*

Construction Material*

Categories of building construction established by Insurance Services Office, Inc. (ISO), in its Commercial Lines Manual (CLM) for purposes of developing rates for insuring commercial property, based on susceptibility to damage by fire.

Frame

Joisted Masonry

Noncombustible

Masonry Noncombustible

Modified Fire Resistive

Fire Resistive

Loss of Income*

With Limit

Without Limit

Deductible Amount*

$250

$500

$1,000

$3,000

$5,000

$10,000

Building Limit*

Protection Class*

Protected

Partly Protected

O/L/T:*

Tenant Occupied

Owner Occupied

Protection Device Credit*

Central Alarm

Local Alarm

None

Area Square Footage*

Check Applicable Options

Sole Occupancy

Replacement Cost Applies

Sprinklered

Theft Exclusion

Policy Limits

A - Building Limit *

B - Personal Property Limit *

C - Loss of Income Limit *

Property Current Carrier*

Losses

Check if any losses occured within the last three years

Umbrella insurance refers to liability insurance that is in excess of specified other policies and also potentially primary insurance for losses not covered by the other policies.

Yes

Date of Loss

Loss Type

Description of Loss:

Property

Who runs the business? Contact name and phone number (for inspection purposes):*

Number of years in business at this location*

What are the hours of operation?*

Property

What are the hours of operation?*

Roof Construction Material*

Asphalt shingle

Tile

Wood shakes

Slate

Metal

Total area occupied by insured?*

Total public areas?*

Other occupancies in the building?*

What is the annual sales/receipts?*

What is the annual payroll?*

Number of employees?*

6. List any location/business interest owned/operated by insured but not listed:

Year built:*

If updated, advise specific year of updated for wiring:

If updated, advise specific year of updated for plumbing:

If updated, advise specific year of updated for heating:

If updated, advise specific year of updated for roofing:

If a retail store, does installation, service or repair work account for more than 25% of receipts?*

Yes

Are you involved in manufacturing, mixing, relabeling, or repackaging of products?*

Yes

Are there any athletic fields or facilities?*

Yes

If an office, please describe type and operations performed:

Are there any bankruptcies, tax or credit liens against the applicant in the past five years?*

Yes

Has any policy cancelled or non-renewed in the past 3 years?*

Yes

During the last five years has any applicant been indicted for or convicted of the crime of fraud, bribery, arson or any other arson related crime in connection with this or any other property?*

Yes

Protection

Alarm CS*

An alarm monitoring center or central monitoring station (also known as "CMS" or wholesale central station) is a company that provides services to monitor burglar, fire and residential alarm systems. The Central Monitoring Station may also provide watchman and supervisory services.

Yes

Sprinklers*

Yes

Other Coverages

Such as tool, equipment, supplies

Other Occupants

Please fill out Class Code, Job Description and Annual Payroll for Each.

1. Class Code Number

Workers compensation class codes are codes that the insurance companies use to identify specific categories of work. For instance, you know a contractor supervisor by his title, however, an insurance company knows him as “5606”.

1. Job Description

1. Annual Payroll

2. Class Code Number

2. Job Description

2. Annual Payroll

3. Class Code Number

3. Job Description

3. Annual Payroll

4. Class Code Number

4. Job Description

4. Annual Payroll

5. Class Code Number

5. Job Description

5. Annual Payroll

Please provide any comments, remarks or questions below:

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Please complete the secure form below. When you submit this form, it will be sent directly to me. If you have any questions please feel free to contact me.

Thank you,

Julia Chirico

Business Owners Form

Named Insured

First

Last

Street*

Street

City*

State*

Zip Code*

Zip Code

Contact Name

First

Last

Phone Number*

Fax Number

Location Same As Address?*

Yes

Email address*

Tax ID *

Business Description (Be Specific)*

Insurance Line

Occurrence Limit:*

Per Occurrence refers to the total amount the insurance company will pay per incident during the policy term. Your “Aggregate” limit is the total amount the insurance company will pay for multiple claims over the course of one policy term (which is often one year).

Fire Limit*

Other*

Number of Employees Excluding Owners*

Number of Owners*

Total Payroll*

Officer Payroll*

Clerical Payroll*

Annual Gross Sales*

Annual Cost of Subcontractors*

Property Current Carrier*

Expiration Date*

Current Date*

Do you want an Umbrella quote?

Umbrella insurance refers to liability insurance that is in excess of specified other policies and also potentially primary insurance for losses not covered by the other policies.

Yes

If yes, what limit?

Property

Current Carrier Company

Expiration Date*

Construction Material*

Frame

Joisted Masonry

Noncombustible

Masonry Noncombustible

Modified Fire Resistive

Fire Resistive

Date*

Loss of Income Limit*

Building Limit*

Contents Limit*

Deductible*

Roof Construction Material*

Asphalt shingle

Tile

Wood shakes

Slate

Metal

List Update Year for the following:

Roof*

Electric*

Heating*

Plumbing*

Protection

Alarm CS*

Yes

Sprinklers*

Yes

Loss of Refrigeration

Other Coverages

Such as tool, equipment, supplies

Other Occupants

Workers Compensation

Current Carrier*

Expiration Date*

Number of Employees*

Current Premium*

Please fill out Class Code, Job Description and Annual Payroll for Each.

1. Class Code Number

1. Job Description

1. Annual Payroll

2. Class Code Number

2. Job Description

2. Annual Payroll

3. Class Code Number

3. Job Description

3. Annual Payroll

4. Class Code Number

4. Job Description

4. Annual Payroll

5. Class Code Number

5. Job Description

5. Annual Payroll

Please list all Executive Officers or Owners

Do you want to cover Officers or Owners?

Is Officer Payroll included above?

Yes

Experience Mod

Comments:

Underwriting

Years Experience*

Years Operating the Business*

Contractors Licence Number*

Is any work performed in New York City or the 5 boroughs?*

Yes

If yes, what percent?*

Do employees use their personal vehicles for your business?*

yes

Do you work in any of the following:*

Townhomes

Condos/Co-Ops

Row Homes

Developments of 15 or more family homes

Percentage of your work as a General Contractor*

Percentage of your work as a Sub Contractor*

Percentage of your work in Residential *

Percentage of your work in Commercial*

Percentage of your work with Renovations*

Percentage of your work with New Construction*

Does the Insured use a written contract with customers? *

Yes

If no, why?*

Does the Insured use a written contract with Subcontractors? *

Yes

If no, why?*

Do contracts contain hold harmless agreements in insureds favor?*

Yes

Are certificates of insurance obtained from all contractors?*

Yes

Is insured added as additional insured on all subcontractors liability policies?*

Yes

Does the insured have Workers Compensation in force?*

Yes

Is Architectural or Engineering Design Provided in service?*

Yes

If yes, please explain:

Are errors and omissions coverage carried for these services?*

Yes

Would you like Errors and Omissions quote?*

Yes

Is the insured a Project Manager or Consultant?*

Yes

Has the insured been involved or will be involved in working on Condos, apartments, or Tract Housing?*

Yes

Has the insured been involved in any claims involving construction defects?*

Yes

Your business website:

Have you ever filed for bankruptcy?*

Yes

Have you operated any other business in the past 5 yrs?*

Yes

If Yes, describe names and current status?

Do you have Commercial Auto's?*

Yes

Would you like a Commercial Auto Quote?*

Yes

Would you Like a Hired/Non Owned Auto Quote?*

Yes

List any claims in the past 5 yrs and give details below:

Please provide any comments, remarks or questions below:

Are you human?*

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Business Owner Form

Business Owner Form

Business Owners Form

Business Owners Form

Policy Information

Building Details

Policy Limits

Losses

Property

Property

Protection

Business Owners Form

Insurance Line

Property

Protection

Workers Compensation

Underwriting

Schreiner - Blaeser Agency Corporation

Services