Commercial Insurance

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New Business/Venture

Existing Business

Section 1

Agency Name

Date

Fax ( AJC. No.):

Policy information

Proposed Eff Date

Proposed Exp Date

Applicant Information

Business Name

Mailing Address (Including ZIP + 4)

FEIN/TIN/SSN

Business Phone #:

Website/URL/IG/FB

Type of business

Add Applicant Information Remove

Contact Information

Role/Position

Contact Name:

Primary Phone #

Secondary Phone #

Primary E-MAIL Address:

Secondary E-MAIL Address:

Add Contact Information Remove

Premises Information (Business office location)

Street

City:

Dropdown

ZIP:

Interest

# Full Time Employees

# Part Time Employees

Annual Revenues

Occupied Area (SQ FT)

Total Building Area: (SQ FT)

Description of operation

Add Premises Information Remove

Nature Of Business

Other

Date Business Started

Description Of Primary Operation

Additional Interest

Interest

Evidence:

Reference / Loans:

Name And Address Rank:

General Information

Is the applicant a subsidiary of another entity?

Description

Parent Company Name

Relationship Description

% Owned

Does the Applicant Have any Subsidiaries?

Description

Subsidiary Company Name

Relationship Description

% Owned

Description

Any Policy Or Coverage Declined, Cancelled Or Non-Renewed During The Prior Three (3) Years For Any Premises Or Operations? (Missouri Applicants - Do not answer this question))

Description

Any Policy Or Coverage Declined, Cancelled Or Non-Renewed During The Prior Three (3) Years For Any Premises Or Operations? (Missouri Applicants - Do not answer this question))

Prior Carrier information

Does Applicant have other business ventures for which coverage is not requested?

Description

Prior Carrier information

Repeater

Date of Occurrence

Type / Description of Occurrence Or Claim

Date of Claim

Amount Paid

Subrogation

Claim Open

Add Remove

Remarks/Description

Signature

PERSONAL INFORMATION ABOUT YOU MAY BE COLLECTED FROM PERSONS OTHER THAN YOU IN CONNECTION WITH THIS APPLICATION FOR INSURANCE PERSONAL INFORMATION AND SUBSEQUENT POLICY RENEWALS. SUCH INFORMATION AS WELL AS OTHER PERSONAL AND PRIVILEGED INFORMATION COLLECTED BY US OR OUR AGENTS MAY IN CERTAIN CIRCUMSTANCES BE DISCLOSED TO THIRD PARTIES WITHOUT YOUR AUTHORIZATION. YOU HAVE THE RIGHT TO REVIEW YOUR PERSON, INFORMATION IN OUR FILES AND CAN REQUEST CORRECTION OF ANY INACCURACIES. A MORE DETAILED DESCRIPTION OF YOUR RIGHTS AND OUR PRACTICES REGARDING SUCH INFORMATION IS AVAILABLE UPON REQUEST. CONTACT YOUR AGENT OR BROKER FOR INSTRUCTIONS ON HOW TO SUBMIT A REQUEST TO US.

I accept the terms

THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT REASONABLE ENQUIRY HAS BEEN MADE TO OBTAIN THE ANSWERS TO QUESTIONS ON THIS APPLICATION. HE/SHE REPRESENTS THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF HIS/HER KNOWLEDGE.

I accept the terms

Applicant's Signature

Clear

Date

Referred/Completed by

Document

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