Business owner's policy on-line application

Date
Named Insured
Mailing Address 1
Mailing Address 2
City
State		AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Zip Code
Proposed Effective Date		/ /
Contact Name
Contact Title
Contact Phone		- -
Please advise Dental Laboratory Association Membership: Yes No - Association Name
General Liability Limit		$2,000,000 Occurence / $4,000,000 Aggregate
Excess Liability Limits		Commercial Umbrella Limit
Property Deductbile		$250 $500 $1,000 $2,500
Hired / Non-Hired Auto Liability		Yes No
If Yes, Is There a Commercial Auto Policy In Force? Yes   No
If Yes, Are non-owned vehicle liability limits a minimum of $100,000? Yes   No
Hired Physical Damage		Yes No
Coastal Property
Building is miles from coast
Location Address
Locations City
Location County
Location State		AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Location Zip
Limits of Insurance - Standard
Building		$
Energy Equipment		Yes No
Business Personal Property		$
Employee Benefit Liability		Yes No
Business Computer:		$10,000
Off Premises		$20,000
Precious Metals		$10,000
Water Damage		$25,000 (Sewer & Drain Backup)
Accounts Receivable		$25,000
Cases in Transit		$15,000
Valuable Papers		$15,000
Employee Dishonesty		$10,000
Business Income: 12 month no dollar limitation, payroll, extra expense & loss of income included
Rating Information
Construction of Building		Frame Joisted Masonry Masonry / Non-Combustible Fire Resistive
		Unsure of what this is, click here to learn more.
Sprinkler System for Fire		Yes   No
Local Alarm		Yes   No
Central Station Alarm		Yes   No
Year Built
If building is over 25 years old, please provide the year the following updates were completed.
Roof
Plumbing
Electrical
Total Area of Building
Area of Vacant Space in Building
Area Leased by Insured
Area Insured Leases to other occupants
Number of Stories
Number of Elevators
Occupancy Type		Retail   Office Residential
Underwriting Information
Years in Business
Hours of Operation
Number of Employees
Annual Sales		$
Any Products Sold Direct to Public:		Yes   No
Any other operations other than Dental Lab:		Yes   No
Current Insurance Carrier
Current Annual Premium
Loss Information
Date of Loss Description of Loss Amount Paid