Care Quote Application

• Site conducted

  Select

• Agent Name

• Submission Date

  Date

• Upload three admitted market declinations. You can submit for review without, but we cannot provide a quote or bind without them.

  Media

• What are the main reasons for the declination?

• Attach any existing policies, acord apps, supplementals, and loss runs

  Media

• Who is the current carrier? Are they offering a renewal?

• Effective Date

  Date

• Expiration Date

  Date

• Legal Entity Type

  Select

• Legal Name

DBA - If business has multiple DBA's (ficticious business names), add additional by pressing the green '+' button below

• DBA Name

Other Named Insured's - If business has multiple Named Insured's, add additional by pressing the green '+' button below

• Named Insured

• Phone Number

• FEIN

• Mailing Address
  Address

• Is this the physical address?

  Yes

  No

  N/A

• Industry (NAIC)

  Select

• SC Care does not typically have an appetite for this industry. Current SafetyCulture Clients and risks that are unique and do not have the typical exposures seen within the industry will be reviewed for exceptions. Would you like to submit for Underwriting consideration?

  Yes

  No

  N/A

• SC Care does not typically have an appetite for this industry. Current SafetyCulture Clients and risks that are unique and do not have the typical exposures seen within the industry will be reviewed for exceptions. Would you like to submit Underwriting consideration?

  Yes

  No

  N/A

• SC Care does not typically have an appetite for this industry. Current SafetyCulture Clients and risks that are unique and do not have the typical exposures seen within the industry will be reviewed for exceptions. Would you like to submit Underwriting consideration?

  Yes

  No

  N/A

• SC Care does not typically have an appetite for this industry. Current SafetyCulture Clients and risks that are unique and do not have the typical exposures seen within the industry will be reviewed for exceptions. Would you like to submit Underwriting consideration?

  Yes

  No

  N/A

• SC Care does not typically have an appetite for this industry. Current SafetyCulture Clients and risks that are unique and do not have the typical exposures seen within the industry will be reviewed for exceptions. Would you like to submit Underwriting consideration?

  Yes

  No

  N/A

• Select the best match:

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• Description of Operations - please provide a summary of what the risk does:

• Year Established

• Website

• If business has multiple locations, add additional locations by pressing the green '+' button below

Location
• Address
  Address

• Number of Executive Officers

• Number of Employees

• Estimated annual gross revenue at this location

• Estimated annual payroll at this location

• Estimated Annual Revenue for Liquor Sales at this Location

• What coverages are you for this location? Select all that apply:

  Select Commercial Property Commercial General Liability Crime Equipment Breakdown Inland Marine Other

  • Commercial Property
  • Commercial General Liability
  • Crime
  • Equipment Breakdown
  • Inland Marine
  • Other

Property

• Square Footage of Building

• Square Footage Occupied by Insured

• Is this location over 30% vacant?

  Yes

  No

  N/A

• Building Occupancy Type

  Select

• Building Construction Date

• Construction Type

  Select

• Number of Stories

• Is building Sprinklered?

  Yes

  No

  N/A

Building updates - input year completed

• Roof

• Plumbing

• HVAC

• Electrical

• Protection Class

  Select

• Building Limit

• Business Personal Property Limit

• Business Personal Property Valuation Type

  Select

• Tenants Improvements & Betterments Limit?

• Personal Property of Others

• Property Deductible

  Select

• Windstorm Deductible

  Select

• General Liability: Limit of Insurance per Occurrence

  Select

• General Liability: Limit of Insurance Aggregate

  Select

• General Liability: Aggregate Limit Per:

  Select

• Products Liability Included?

  Yes

  No

  N/A

• Products Liability Aggregate

  Select

• If you manufacture, relabel, or directly import any products, please list them here:

• Personal & Advertising Injury Included in Per Occurrence and Aggregate CGL coverage?

  Select

• Damage to Premises Rented to You Limit ($)

  Select

• Medical Payments ($)

  Select

• Hired & Non-Owned Auto Liability

  Yes

  No

  N/A

• Does the business own any vehicles?

  Yes

  No

  N/A

• How many employees use their personal vehicles for work?

• How many times per year do employees use their personal vehicles for work

  Select

• Does the risk require employees to carry at least the minimum required insurance coverage per their resident state?

  Yes

  No

  N/A

• Does the risk collect proof of personal insurance?

  Yes

  No

  N/A

• How many times per year are vehicles rented for the business?

• Employee Benefits Limit

  Select

• What ERISA limit would be needed?

• Add $1,000,000 of Liquor Liability?

  Yes

  No

  N/A

• Are there any Additional Insureds required?

  Yes

  No

  N/A

• Blanket Additional Insured as Required by a Contract is Included in this quote

• Any Scheduled Additional Insured's Required?

  Yes

  No

  N/A

• If business has multiple additional insureds, add additional insureds by pressing the green '+' button below

Additional Insured

• What type of Additional Insured is required

  Select

• What is the name of the Additional Insured?

• What is the Additional Insured's Address?
  Address

• Waiver of Subrogation as required by Contract needed?

  Yes

  No

  N/A

• Primary & Non-Contributory Wording needed as required by contract?

  Yes

  No

  N/A

• What Crime coverage and limits do you need?

• What type of Equipment?

• What Limit of Equipment Breakdown do you need?

• Has the risk installed sensors? Or will the risk consider installing Sensors? *SafetyCulture is able to provide these at a discount and help them with the instalation

  Yes

  No

  N/A

• What is the risk needing to over? Provide description and coverage amounts. You may attach documents showing schedules here as well.

• Has the risk had any claims in the past 5 years?

  Yes

  No

  N/A

• If business has multiple claims in last 5 years, add additional claims by pressing the green '+' button below

Claim

• Claim type:

  Select

• Claim date:

  Date

• Description:

• Paid: ($)

• Reserve: ($)

• Open/Closed

  Open

  Closed

• Risk Approved?

  Yes

  No

  N/A

• Is risk declined?

  Yes

  No

  N/A

• What is the declination reason?

• What else does the underwriter require to review the risk?

• Are there any subjectivities?

• Are there any coverage conditions that do not match the application?

• Premium?

• Taxes

• Fees

• Attach proposal here

  Media

• Date of approval

  Date

• Approver's signature

  Sign