New Business Application

and Submission Cover Page for Faxing

Click for Contractor's Pollution, Equipment and Builders Risk quotations.
Click for Auto quotations.

Click on and print the forms pertinent to your business. Fax or email them to us.

 

General information

Company name
Contact name
Address
City
State
Zip code
Phone (with area code)  
Fax  
Email
Description of Operations
Business structure
Officer Information (please establish ownership to 100%)
(FEIN) Federal Employer ID   (this will be your submission tracking number)
Years in business
Number of full-time employees
Number of part-time employees
Expiring carrier & premium
Types of Coverage requested
 

 

Additional Information REQUIRED

DO NOT SEND UNTIL ALL BOXES BELOW CAN BE MARKED YES
WHEN WE HAVE RECEIVED THE SUBMISSION YOU WILL GET A
CONFIRMATION FORM AND THE FEIN IS THE SUBMISSION
TRACKING NUMBER.
o Yes  o No Prior 5 Yrs Hard Copy Loss Info (currently valued)
o Yes  o No Sample Client/Sub Contractor Agreement
o Yes  o No Company Financial Information
o Yes  o No Experience Modification Factor (for workers compensation only)
o Yes  o No Expiring Declarations Page from Current Carrier
o Yes  o No ACORD applications (125 App Info and other relative apps)
o Yes  o No Are you an agent or broker?

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