Business Information
Business Legal Name *
DBA (Doing Business As)
Business Entity Type *
Select Type
Sole Proprietorship
Partnership
LLC
Corporation
S-Corporation
Non-Profit
Primary Industry/Business Type *
Select Industry
General Contractor
Electrician
Plumber
HVAC
Carpenter
Painter
Landscaper
Roofer
Consultant
Accountant
Real Estate
Insurance Agent
Marketing Agency
IT Services
Retail Store
Restaurant
Bar/Nightclub
Hotel/Motel
Salon/Spa
Gym/Fitness Center
Medical Office
Dental Practice
Chiropractor
Physical Therapy
Home Health Care
Manufacturer
Distributor
Wholesaler
Warehouse
Cleaning/Janitorial
Property Management
Auto Repair
Photography
Event Planning
Other
Detailed Business Description *
Year Business Started *
Years of Industry Experience *
Federal Tax ID (EIN)
Professional Licenses/Certifications
Business Operations
Annual Gross Revenue *
Select Range
Under $50,000
$50,000 - $100,000
$100,000 - $250,000
$250,000 - $500,000
$500,000 - $1 Million
$1M - $2.5M
$2.5M - $5M
$5M - $10M
Over $10M
Projected Next Year Revenue
Select Range
Under $50,000
$50,000 - $100,000
$100,000 - $250,000
$250,000 - $500,000
$500,000 - $1 Million
$1M - $2.5M
$2.5M - $5M
Over $5M
Number of Owners/Partners *
Select
1
2
3
4
5 or more
Number of Employees *
Select Range
No Employees
1-2
3-5
6-10
11-25
26-50
51-100
Over 100
Full-Time Employees
Part-Time Employees
1099 Contractors
Total Annual Payroll
Business Locations
Primary Business Address *
City *
State *
Select State
Ohio
Pennsylvania
Michigan
Indiana
West Virginia
Kentucky
ZIP Code *
Number of Business Locations *
Select
1
2
3
4
5
6-10
More than 10
Risk Exposure & Operations
Largest Project/Contract Value
Typical Project/Contract Value
Coverage Requirements
Per Occurrence Limit *
Select Limit
$300,000
$500,000
$1,000,000
$2,000,000
$3,000,000
$5,000,000
General Aggregate Limit *
Select Limit
$600,000
$1,000,000
$2,000,000
$4,000,000
$6,000,000
$10,000,000
Products/Completed Operations
Select Limit
Included in Aggregate
$1,000,000
$2,000,000
$4,000,000
Medical Payments
Select Limit
No Coverage
$5,000
$10,000
$15,000
Claims & Insurance History
Contact Information
Contact Name *
Title/Position *
Email Address *
Phone Number *
Desired Coverage Start Date *
Current Insurance Carrier
Additional Information