Commercial Insurance Application

• Conducted on

  Date

• Prepared by

• Brokerage

  Select

• Named Insured

• Do you have acord applications or another application ready?

  Yes

  No

  N/A

• What Lines of Business are needed?

  Select Other Specialty Insurance Commercial Property General Liability Workers' Compensation Commercial Auto Commercial Umbrella

  • Other Specialty Insurance
  • Commercial Property
  • General Liability
  • Workers' Compensation
  • Commercial Auto
  • Commercial Umbrella

Other Specialty Insurance

• What other Insurance product is needed?

• Effective date?

  Date

• Expiration date?

  Date

• Does current coverage exist?

  Yes

  No

  N/A

• Please attach copy of current coverage

  Media

• Please attach current loss runs for this coverage

  Media

• Please describe what limits are needed

Commercial Property

• Is there current coverage?

  Yes

  No

  N/A

• Please attach copy of current policy

  Media

• Please attach current loss runs

  Media

• Please provide a schedule of the locations needing coverage and what limits they require

  Media

General Liability

• Is there current coverage?

  Yes

  No

  N/A

• Please attach copy of current policy

  Media

• Please attach current loss runs

  Media

• Please describe the risk's operations

• Provide risk's website

• What is risk's Gross Revenue?

• What is risk's estimated Annual Payroll?

• What is the Sqft of the business?

• What limits of coverage are they looking for?

• Are there any contractual requirements? Describe or attach contract

Workers' Compensation

• Is there current coverage?

  Yes

  No

  N/A

• Please attach copy of current policy

  Media

• Please attach current loss runs

  Media

• Please provide # of employees and payroll by WC class

  Media

Commercial Auto

• Is there current coverage?

  Yes

  No

  N/A

• Please attach copy of current policy

  Media

• Please attach current loss runs

  Media

• Please attach current MVR's

  Media

• Please provide a schedule vehicles and drivers

  Media

• Please provide details on the coverage limits they are requesting

• Please provide current MVR's

  Media

Commercial Umbrella

• Is there current coverage?

  Yes

  No

  N/A

• Please attach copy of current policy

  Media

• Please attach current loss runs

  Media

• Please provide info on limits needed and coverages that they'd like to place as underlying

• Please attach all acord applications

  Media

• Please attach all current loss runs

  Media

• Check this box to alert SC Care Underwriter