Commercial EZ-App

Step 1 of 2: Submit

For Fast service on your commercial accounts complete the form below and click "Continue". Your submission will be electronically delivered to the next available Commercial Lines Underwriter.

Coverage Requested Package (Please fill out entire application) Monoline Liability Monoline Property

Applicant Name: Applicant Website Address Location address: Applicants Primary Telephone #: Description of Risk:

Prior Losses? Yes (If Yes, include 5 years hard copy loss runs with submission) No

Has applicant had any policies or coverage's cancelled or non-renewed in the past three years? Yes No

Has applicant had prior Bankruptcy in the past 7 years? Yes No

Have any crimes occurred or been attempted on the premises with the last 3 years? Yes No

Expiring Carrier:

Willing to Renew? Yes No

If you selected not to Renew, why? Renewal Quote: $ Target Premium: $

General Liability ( Fill out if you choose Package or Monoline Liability)

Limits Requested: $ Payroll: $ Number of Employees?: Receipts: $ Square Footage: If Apt., # of Units: Years in Business:

Does the applicant lease Employees Yes No

Property ( Fill out if you choose Package or Monoline Property)

Building: $ Contents: $ Loss of Income: $ Protection Class: Construction Type: Square Feet:

Sprinkler?: Yes No

Central Alarm?: Yes No

Year Built:

Is Building 100 percent on Circuit Breakers?: Yes No

If over 20 years old, provide building updates:

Building Updates / (Year)

Wiring (Yr): Roof (Yr) Heating/Air (Yr): Plumbing (Yr): What is the quality of house keeping?

Is the Applicant:

(a) An owner of any other properties or business operations under this legal entity?
(b) Related to another entity through common ownership?
(c) Subsidiary of another entity?

If yes to any of the above please explain. Agency Name: Contact Person: Phone Number: Fax Number: Email Address: