Business Name*:
Does the insured have a DBA?* Yes/No: If yes:
Legal Entity* Sole Proprietor/Corporation/LLC/Partnership/Association/Trust:
FEIN/SSN:
SIC and/or NAICS:
Is the insured a general contractor (class B license), that subs out more than 25% of their work?*: Yes/No
Are any of the locations in this submission outside of the state of California?*: Yes/No
Insured Contact Name*:
Insured Business Phone Number*:
Insured Cell Number:
Insured Fax Number:
Insured Email Address*:
Business Website*:
Mailing Address*:
Street:
City:
State:
ZIP Code:
Desired Effective Date For New Policy*:
Nature of Business*:
Brief description about the business operations:
Have the insured’s operations changed due to COVID-19? Yes/No If YES please describe how so. *:
Is the insured’s business currently closed due to COVID-19? If YES please explain when they plan to reopen.*:
Has the insured had any claims that are related to COVID-19? If YES please give details.*:
Is the insured compliant with all CDC safety controls in relation to COVID-19? If NO please provide details.*:
Year Business Was Established*:
Number of Years of Management Experience *:
Briefly describe the details of the management experience:*:
Gross Sales (All Locations)*: $
Gross Sales From Internet (All Locations)*: $
Number of Employees *:
Annual Payroll*: $
Any losses in the past five years?*: Yes/No
General Liability Per Occurrence/Aggregate*: 1 million / 2 million OR 2 million / 4 million
How many locations are there?*: 1/2/More than two
Same As Mailing Address? Yes/No If no:
Location 1 Street Address *:
City:
State:
ZIP Code:
Location 1 Construction Type *:
For construction descriptions: http://www.amrisc.com/Amrisc%20pdfs/CompleteSOV/ISOTypesDescriptions.pdf
Location 1 Roof Type*:
Location 1 Year Built *:
Location 1 Building Updates: Is the building older than 20 years?*: No/Yes
**If building older than 20 years and no updates are provided, quoting may be delayed**
Location 1 Occupancy*: Single Occupancy/Multiple Occupancy
Location 1 Total Square Feet of Building*:
Location 1 Total Square Feet Occupied by Insured*:
Location 1 Square Feet Occupied by Other Building Tenants*:
Location 1 Square Feet Unoccupied*:
Location 1 Number of Stories Ocupied *:
Location 1 – Protective Devices*: Fire/Theft/Central Station
Check all that apply **Credits may be available for central station, proof may be required.
Location 1 Type of Smoke Detectors*: Hard Wire/Battery/Lithium Battery
Location 1 – Sprinkler %*: 100%/80% – 99%/<80%/None
Location 1 Contractor responsible for sprinkler sytem maintenance and inspection (indicate frequency)*: Yes-Monthly/Yes-Quarterly/Yes-Semi-Annually/Yes-Annually/No/
Location 1 Interest*: Tenant/Owner – Owner Occupied/Owner – Tenant Occupied (Lessors Risk)/Other:
Location 1 Building Limit *: $
Enter “0” if tenant or not needed
Location 1 Business Personal Property Limit*: $
Location 1 Deductible *: $250/$500/$1000/$2500/$5000/$10000/Other:
Location 1 Gross Sales*: $
Location 1 Gross Sales From Internet*: $
Enter “0” if none
Location 1 Is there any Additional Interest?*: None/Landlord/Additional Insured/Mortgagee/Other:/Other Value
Location 1 Additional Interest Name:
Location 1 Additional Interest Address:
City:
State:
ZIP Code:
Other Coverage Needed
Hired / Non-owned Coverage*: Yes/No
Umbrella Coverage Requested*: Yes/No
Other Additional Coverages Required*: Yes/No
Describe additional coverages requested: