|
Apply Online
If you
would like to receive a quote for business insurance, please complete
and submit this online application. 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, click
HERE for contact
information
*Mandatory
fields |
|
|
Please
check the lines of insurance that you would like us to quote for you:
Property
General
Liability
Workers
Compensation
Automobile |
|
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?
1-3
4-7
8-10
10+
Type of Industry
Please describe
business operations:
Please enter total
number of employees:
Full Time
Part Time
Requested Coverage Effective Date
(mm/dd/yy)
List current insurer(s)
|
|
Property Insurance |
|
Primary Location
|
|
Do you own or
lease this location?
Own
Lease
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?
sq. ft.
What is your
building constructed of?
|
Does your
building have an alarm?
Yes
No
Is your building
sprinklered?
Yes
No
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?
Yes
No
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?
Own
Lease
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?
sq. ft.
What is your
building constructed of?
|
Does your
building have an alarm?
Yes
No
Is your building
sprinklered?
Yes
No
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?
Yes
No
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 &
Workers Compensation |
|
General Liability Limit
(per occurrence/aggregate)
|
Federal Employee
Identification Number
(e.g. 123-45-6789) |
|
Annual Revenues to Your
Business
|
Employee Description
|
|
Annual Payroll
|
Executive Officers
Excluded
Yes
No |
|
What percentage of your
sales derive from
Internet-based sales?
|
Names of Officers and
Corporate Titles
|
|
Umbrella Limit
|
|
Employer's Liability
Limit
|
Any General Liability or
WC losses in the last 5 years?
Yes
No |
|
Annual
Payroll Amounts |
Describe any
losses/claims including year of
occurrence, description
and total amounts paid.
|
|
Clerical - 8810
Outside Salespersons -
8742
Executive Officers -
8809
Other |
|
Automobile Insurance |
|
Hired and
Non-Owned exposure only?
(click for more info)
Yes
No |
Describe any
auto losses/claims including year of
occurrence, description
and total amounts paid.
|
|
Do you rent cars for
business use?
Yes
No |
|
|
|
|
