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Business Insurance Application

 

Business Information

 

Legal Name of Business

Doing Business As (DBA)

Business Address

 

City

State/Province

Postal/Zip Code

Mailing Address (if different)

 

City

State/Province

Postal/Zip Code

Website Address

Business Phone Number

Business Email Address

Type of Business

Date Business Established

Number of Employees

Annual Gross Revenue (Projected)

Description of Business Operations.

Detailed description of what the business does, including specific activities, products, or services offered.

 

Coverage Information

 

Please take a moment to review the subsequent choices and then select the one that best corresponds to your needs.

Type of Insurance Requested

Check all that apply

Desired Coverage Limits

Deductible Amounts

A
B
C
D
1
General Liability
 
 
2
Commercial Property
 
 
3
Workers' Compensation
 
 
4
Professional Liability (Errors & Omissions)
 
 
5
Business Interruption
 
 
6
Cyber Liability
 
 
 

Prior Insurance Coverage

 

Have you had prior business insurance?

 

If yes, please provide.

Insurance Company Name

Policy Number

Coverage Date

Reason for Cancelation or Non-Renewal

A
B
C
D
1
 
 
 
 
2
 
 
 
 
3
 
 
 
 
4
 
 
 
 
 

Property Information

 

Location of Property (Enter Address of Property to be Insured)

 

City

State/Province

Postal/Zip Code

Building Type

Construction Materials

Age of Building

Square Footage

Occupancy

Security Features

Value of Building (Replacement Cost)

Value of Business Personal Property

Claims History

 

Please provide details for each insurance claim in the past five years.


Insurance Company Name

Policy Number

Coverage Date

Reason for Cancelation or Non-Renewal

A
B
C
D
1
 
 
 
 
2
 
 
 
 
3
 
 
 
 
4
 
 
 
 
 

Applicant Information

 

Title

First Name

Last Name

Phone Number

Email Address

Declarations and Signatures

 

I certify that the information provided in this application is true and accurate to the best of my knowledge. I understand that any misrepresentation or omission of material facts may result in the denial of coverage or the cancellation of my policy.

 

Signature of Applicant

 

Notes

  • It's crucial to provide complete and accurate information throughout the application. Any misrepresentation or omission can lead to denial of coverage or policy cancellation.
  • Consult with an Insurance Professional: If you have any questions or need assistance in completing the application, don't hesitate to seek guidance from an insurance broker or agent. They can help you understand the different coverage options, determine appropriate limits, and navigate the application process.
  • Review your Policy Carefully: Once you receive your insurance policy, thoroughly review all terms, conditions, exclusions, and limitations to ensure you have the coverage you need.
 

Form Template Insight

Please remove this form template insight section before publishing.


Important: This is a sample application only. You must contact an insurance company or broker to obtain the appropriate application for your business needs. Do not use this form to apply for insurance.


1. Business Information:

  • This section establishes the identity and nature of your business. Accurate and detailed information is essential for proper risk assessment.
  • Type of Business: This is critical as different industries have varying levels of risk. A construction company will have different needs than a consulting firm.
  • Description of Business Operations: This is your chance to clearly explain what your business does. The more specific you are, the better the insurer can understand your risks.
  • Annual Gross Revenue: This helps insurers gauge the size and scale of your operations, which influences potential claim amounts.

2. Coverage Information:

  • This section outlines the types of insurance you need and the desired level of protection.
  • Types of Insurance Requested: This is where you select the specific coverages relevant to your business, such as general liability, property, workers' compensation, etc.
  • Desired Coverage Limits: You specify the maximum amount the insurer will pay for a covered claim. This requires careful consideration of your potential risks and financial capacity.
  • Deductible Options: You choose the amount you'll pay out-of-pocket for each claim. Higher deductibles usually result in lower premiums.
  • Prior Insurance Coverage: Providing details about your past insurance history helps insurers understand your experience and identify any potential red flags.

3. Property Information (If applicable):

  • This section is crucial if you're seeking coverage for your business premises or assets.
  • Location, Building Type, Construction Materials, Age of Building: These factors influence the property's vulnerability to risks like fire, theft, or natural disasters.
  • Security Features: The presence of security systems, alarms, and other protective measures can reduce your risk profile and potentially lower premiums.
  • Value of Building and Business Personal Property: Accurate valuations are essential to ensure you have adequate coverage to rebuild or replace your assets in case of a loss.

4. Claims History:

  • This section requires you to disclose any past insurance claims. Insurers use this information to assess your claims frequency and identify potential patterns.
  • Details of each claim: Be prepared to provide specific information about the date, description, amount, and status of each claim.

5. Applicant Information:

  • This section gathers information about the person applying for the insurance on behalf of the business.

6. Declarations and Signatures:

  • This section includes a statement confirming the accuracy of the information provided and authorizing the insurer to rely on it.
  • Signature: A legally binding signature is required to validate the application.

By understanding the purpose and importance of each section in a business insurance application, you can increase your chances of securing the right coverage at the best possible price.

 

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