Commercial Property & General Liability

QUOTE REQUEST

Please fill in as much information as possible, as it will help us serve you more effectively.

Applicant Information

Your Name (required)

Mailing Address
 

City

State

Zip Code

Phone

Fax

E-Mail (required)

Firm Information

Firm Name

Physical Address

City

State

Zip Code

Years In Business

Estimated Annual Sales
$

Estimated Annual Payroll
$

Number of Full Time Employees

Number of Part Time Employees

Number of Leased Employees

Legal Entity
Individual
Partnership
Corporation

LLC
Joint Venture
Other

Nature of Business
Office  

            Type
Service

          Type  
Retail

           Type  

Wholesale

           Type  
Restaurant

           Type  
Contractor

           Type  

General Information

Do/Have past, present, or discontinued operations involved storing, treating, discharging, applying, disposing, or transporting hazardous materials?
Yes  No 

 Are athletic teams sponsored?
Yes  No

Are subcontractors allowed to work without providing a certificate of insurance?
Yes  No

During the last five years (ten if Rhode Island), have any applicant been convicted of any degree of crime or arson?
Yes  No

Any coverage ever been declined, cancelled, or non-renewed within three years?
Yes  No 

Do you lease employees to or from other employers?
Yes  No

Any workers compensation carried?
Yes  No

Do you own or operate any other businesses?
Yes  No

Are you involved in manufacturing, mixing, relabeling, or repacking of products?
Yes  No

Has applicant had a foreclosure, repossession, bankruptcy, judgment or lien during the past five years?
Yes  No 

Any exposure to flammables, explosives, or chemicals?
Yes  No

Any catastrophe exposure?
Yes  No

Any past losses or claims relating to sexual abuse or molestation allegations, discriminating or negligent hiring?
Yes  No

Any uncorrected fire code violations?
Yes  No

Liability

General Liability Limit

$1million   $2million   $3million   $4million   $5million   Other  $

Hired Auto Liability

  Yes  No

Non-Owned Auto Liability

  Yes  No

Employee Benefits Liability

Yes  No

Property

Interest
Owner
Tenant

Building Information

Total Square Feet
square ft.

Square Feet Occupied
square ft.

Percentage of Whole Occupied

Year Constructed

Number of Stories

Distance to Fire Hydrant
ft.

Distance to Fire Station
mi.

 Does applicant have a heating or processing boiler?
Yes  No

          if yes, indicate year of last inspection
         

 Any specialized equipment valued over $100,000?
Yes  No

 Is all equipment inspected annually and well maintained?
Yes  No

Building Construction
Wooden Frame
Wood & Masonry
Masonry Veneer

Masonry/Block
Steel Frame

Masonry & Steel

Building Protection

Burglar Alarm System to
Alarm Company  Police Station  Local

Is there a sprinkler system?
Yes  No

Building Improvements

           Wiring Year

           Roofing Year

           Plumbing Year

           Heating Year

Coverages

Building Limit

$

Contents Limit

$

Personal Property Limit
$

Deductable

$  

Additional Coverages

Valuable Papers

$

Signage

$

Employee Dishonesty

$

Money Inside

$

Money Outside

$

Spoilage

$

Computers

$

Flood

$

Earthquake

$

Ground Floor Glass

ft

Comments

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