Commercial Coverage Worksheet/Application
If you would like to receive a quote for business insurance, or change your coverage, please complete the applicable section of this application and fax it to: HUDSON & MUMA, COMMERCIAL DEPARTMENT, 248-549-6452. If you would prefer to provide your information via telephone with a service representative, please call 248-549-3519. We ensure the confidentiality of your information, HERE for contact information
*Mandatory fields
Please check the lines of insurance that you would like us to quote for you:
Information About Your Company
Name of Business
Legal Name of Business*
Business Address
Mailing Address
Contact Person*
Telephone*
Fax
E-Mail Address*
Website (if applicable)
How many years has the company been in business?
Type of Industry
[ Select ]
Manufacturing
Office
Retail
Service
Technical
Wholesale
Other
Please describe business operations:
Please enter total number of employees:
Requested Coverage Effective Date (mm/dd/yy)
List current insurer(s)
Primary Location
Do you own or lease this location?
Building Address
If you own the building, what is building replacement value?
What is the total value of your Business Personal Property?
(e.g. furniture, fixtures, equipment, machinery, stock, etc.)
What is the sq. footage of your current space/bldg?
What is your building constructed of?
[ Select ]
Frame
Joisted Masonry
Non-Combustible
Masonry Non-Combustible
Modified Fire Resistive
Fire Resistive
Heavy Timber
Superior Non-Combustible
Superior Masonry Non-Combustible
Does your building have an alarm?
Is your building sprinklered?
How many stories are in your building?
What floor is your office on?
Year of Construction (e.g. 1986)
If the building is over 30 years old, please describe current renovations:
Any losses at this location in the last 5 years?
Please describe any losses, year of occurrence, description and total amount paid at this location.
Location 2 (if applicable)
Do you own or lease this location?
Building Address
If you own the building, what is building replacement value?
What is the total value of your Business Personal Property?
(e.g. furniture, fixtures, equipment, machinery, stock, etc.)
What is the sq. footage of your current space/bldg?
What is your building constructed of?
[ Select ]
Frame
Joisted Masonry
Non-Combustible
Masonry Non-Combustible
Modified Fire Resistive
Fire Resistive
Heavy Timber
Superior Non-Combustible
Superior Masonry Non-Combustible
Does your building have an alarm?
Is your building sprinklered?
How many stories are in your building?
What floor is your office on?
Year of Construction (e.g. 1986)
If the building is over 30 years old, please describe current renovations:
Any losses at this location in the last 5 years?
Please describe any losses, year of occurrence, description and total amount paid at this location.
* If you have more than two locations, please contact us HERE
General Liability Limit (per occurrence/aggregate)
[ Select ]
$1,000,000 / $2,000,000
$2,000,000 / $4,000,000
Federal Employee Identification Number
Annual Revenues to Your Business
Employee Description
[ Select ]
Clerical - 8810
Outside Salesperson - 8742
Executive Officers - 8809
Other
Annual Payroll
Executive Officers Excluded
What percentage of your sales derive from
Internet-based sales?
Names of Officers and Corporate Titles
Umbrella Limit
[ Select ]
$1,000,000
$3,000,000
$5,000,000
Employer's Liability Limit
[ Select ]
$100,000
$500,000
$1,000,000
Any General Liability or WC losses in the last 5 years?
Annual Payroll Amounts
Describe any losses/claims including year of
occurrence, description and total amounts paid.
Automobile Insurance
Hired and Non-Owned exposure only? (click for more info )
Describe any auto losses/claims including year of
occurrence, description and total amounts paid.
Do you rent cars for business use?
