Business Insurance Application Step 1 of 6 16% Business InformationThis field is hidden when viewing the formBroker NameCarried from the shortcode.This field is hidden when viewing the formBroker EmailCarried from the shortcode. This field is hidden when viewing the formClient Name First Last This field is hidden when viewing the formClient PhoneThis field is hidden when viewing the formClient Email This field is hidden when viewing the formNeed By / Expiration Date MM slash DD slash YYYY Legal Entity NameDBAEntity TypeSelectIndividualCorporationLimited Liability Company (LLC)TrustOtherYear Business StartedWebsiteFEINCurrent Insurance CarrierMailing Address Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Business SummaryPlease provide a 2 - 4 sentence overview of your business and operations: Financials & OperationsLeadership Years' ExperienceEstimated Annual Gross RevenueEstimated Annual PayrollNumber of Part-Time EmployeesNumber of Full-Time EmployeesDo you have a physical business location or office?SelectYesNo Claims HistoryAny insurance claims in the last 5 years?SelectYesNoWere any claims over $20,000?SelectYesNo Primary Physical LocationPrimary Location Address Street Address City StateAlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Total Occupied Square FeetHow much Business Property is owned by you?This includes Furniture/Fixtures/Equipment, Inventory, and Personal belongings.How much Tenant Improvement coverage is requested?Physical changes or additions made by a tenant to customize a rented space for their business needs, such as installing fixtures, flooring, walls, or equipment.SelectNot SureNone$5,000$10,000$25,000$50,000Over $50,000Is there an Additional Interest/Lienholder?SelectYesNoCentral Alarm connected to a monthly service:Please ChooseYesNoCentral Fire connected to a monthly service:Please ChooseYesNoIs the building sprinkled:Please ChooseFull SprinkledPartially SprinkledNot SprinkledAre there any additional locations?SelectYesNo VehiclesDo you have any vehicles owned by the company?SelectYesNoDo any employees drive their personal vehicles during business hours?SelectYesNo Δ