Commercial Fast App — Agent Entered

Step 1 of 14

Client ID(Required)

Account Owner(Required)

Name of Business(Required)

Website(Required)

Lead Source(Required)

Referred By

First Last

1st Point of Contact(Required)

First Last

1st Point of Contact Office Number(Required)

1st Point of Contact Mobile Number(Required)

1st Point of Contact Email(Required)

Desired Effective Date(Required)

MM slash DD slash YYYY

How Many Owners?(Required)

Is the owner the same as the first point of contact(Required)

YES

1st Owner Name(Required)

First Last

1st Owner % of Ownership(Required)

Please enter a number from 1 to 100.

1st Owner Email(Required)

2nd Owner Name(Required)

First Last

2nd Owner % of Ownership(Required)

Please enter a number from 1 to 100.

2nd Owner Email(Required)

3rd Owner Name(Required)

First Last

3rd Owner % of Ownership(Required)

Please enter a number from 1 to 100.

3rd Owner Email(Required)

4th Owner Name(Required)

First Last

4th Owner % of Ownership(Required)

Please enter a number from 1 to 100.

4th Owner Email(Required)

5th Owner Name(Required)

First Last

5th Owner % of Ownership(Required)

Please enter a number from 1 to 100.

5th Owner Email(Required)

FEIN(Required)

(Enter N/A if FEIN is unknown)

SSN (If no FEIN)(Required)

Mailing Address(Required)

Address Line 1 City State Zip

Is your physical address same as your mailing address(Required)

YES

Physical Address(Required)

Address Line 1 City State Zip

Entity Type(Required)

CORP

LLC

SOLE PROP

Other

Any Subsidiaries?(Required)

YES

Description of Operations(Required)

Date Business Started

MM slash DD slash YYYY

Years of Experience (Owner)

Years in business

Current Insurance Company

Expiration Date of Current Policy

MM slash DD slash YYYY

Reason For Shopping Insurance(Required)

Projected Annual Gross Receipts(Required)

Projected Annual Payroll(Required)

# Full Time Employees(Required)

# Part Time Employees(Required)

Do you have any contract (insurance) requirements(Required)

YES

Insurance Requirement Uploads

Drop files here or

Max. file size: 20 MB.

Any Losses in the Last 5 Years?(Required)

YES

Date, Description, and Estimate of Loss(Required)

Do you have a business continuation plan(Required)

Is it funded?(Required)

YES

Would you like to discuss/review funding plans(Required)

YES

Would you like to learn more about this subject (Required)

Coverage Requested

Coverages Requested(Required)

General Liability

Property

Auto

Workers Comp

Errors and Omissions

Cyber

Inland Marine

Builders Risk

Umbrella

Bond

Crime

Group Health

Cargo

Directors and Officers

Executive Bonus Plans

Other

Other Coverage Details(Required)

Please provide coverage details and limits requested

Commercial General Liability

Square Footage you occupy or own(Required)

Do you Own or Lease your space(Required)

Own

Lease

Both

Liability Limits Requested(Required)

Are you a Contractor or General Contractor?(Required)

Contractor

General Contractor

Neither

Do you use Sub Contractors?(Required)

YES

Insured Sub Costs(Required)

Uninsured Sub Costs(Required)

Type of Work Subcontracted out to Insured Subcontractors(Required)

Type of Work Subcontracted out to Uninsured Subcontractors(Required)

% Residential work(Required)

% Commercial Work(Required)

Any Additional Insureds(Required)

Please enter a number from 1 to 100.

Any Waivers of Subrogation?(Required)

YES

Description of Work(Required)

Do Employees use their own vehicles in the business?(Required)

YES

General Liability Additional Notes

Commercial Property

How many locations do you own or lease(Required)

Location Details

Please add an entry for each location.

Business Personal Property	Actions

There are no Entries.

Maximum number of entries reached.

Commercial Auto

Do you have a Driver List file available for upload

Driver List

Drop files here or

Max. file size: 20 MB.

Please drag and drop your driver list here

How many drivers do you have?(Required)

Driver Details

Please add an entry for each driver.

Name	Actions

There are no Entries.

Maximum number of entries reached.

Vehicles

Desired Liability Coverage(Required)

Uninsured Motorist(Required)

Personal Injury Protection(Required)

Comp & Collision Deductibles(Required)

Rental Reimbursement(Required)

YES

Roadside(Required)

YES

Do any vehicles require "Filings"(Required)

Are all vehicles titled in the name of your business(Required)

YES

Title Variations(Required)

Identify the vehicles titled outside of the business and who is on the title for each

Do you have a vehicle list file available to upload(Required)

YES

Vehicle List

Drop files here or

Max. file size: 20 MB.

How many business vehicles do you own?(Required)

Vehicle Details

Please add an entry for each vehicle

Model	VIN	Actions

There are no Entries.

Maximum number of entries reached.

Workers Compensation

Owner Details

Please add an entry for each owner.

Name	Title	Actions

There are no Entries.

Maximum number of entries reached.

Does your business have a documented Safety Program(Required)

YES

Safety Progam Documents

Drop files here or

Max. file size: 20 MB.

Employee/Payroll Category

*Note: Employees Category Examples: Clerical, Driver, Technician, Retail, Electricians, HVAC, Plumbers, Artisan Contractor

Employee Category(Required)

See note above

# of Employees(Required)

Please enter a number from 1 to 100.

Payroll Total(Required)

Workers Comp Additional Notes

Errors and Ommissions

Limits of Liability(Required)

Errors and Ommissions Additional Notes

Cyber

Desired Limits of Liability(Required)

Cyber Additional Notes

Directors and Officers

Desired Limits(Required)

Directors and Officers Additional Notes

Inland Marine

Inland Marine Schedule - Mobile Equipment

Do you have an Equipment List to upload(Required)

Yes

Equipment List

Drop files here or

Max. file size: 20 MB.

Inland Marine

Schedule any item values at $500 or more.

Item Description(Required)

Serial #(Required)

Make/Model(Required)

Item Value(Required)

Tools/Equipment Value

Please add an entry for tool/equipment value/

Row ID	Actions

There are no Entries.

Maximum number of entries reached.

Inland Marine Addtional Notes

Crime

Desired Limits of Liability(Required)

Crime Additional Notes

Umbrella

Liability Limits

Deductible

Umbrella Additional Notes(Required)

Group Health

Company Desired Coverages(Required)

Major Medical

Dental

Vision

Life

Short Term Disability

Long Term Disability

Other Ancillary Coverages

We require a Census. Choose your method

Census Template (Download)

Upload Completed Census(Required)

Drop files here or

Max. file size: 20 MB.

Employee Info

Configuration Required
Use the Nested Form and Summary Fields settings to choose the form and fields to display in this Nested Form field.

Please add an entry for each of the employee

Builders Risk

Owner Name(Required)

First Last

Builder Name(Required)

First Last

Are you the Owner or Contractor(Required)

Onwer

Contractor

Property Location Address(Required)

AddressLine 1 Address Line 2 City State Zip Code

Are we insuring the existing structure?(Required)

Yes

What is the Actual Cash Value of the existing structure?(Required)

Will the structure be occupied during construction?(Required)

Yes

How Many Buildings At This Location

Building Details

Cost of Labor	Cost of Materials	Actions

There are no Entries.

Maximum number of entries reached.

Please Add Entry to record your Building Details

Inside City Limits(Required)

Yes

Distance to Fire Hydrant(Required)

Distance to Fire Station(Required)

Remodel or New Construction(Required)

Remodel

New Construction

Pre Construction Value(Required)

Year of original Construction(Required)

MM slash DD slash YYYY

Description of Renovations

Has Construction Begun(Required)

Yes

Construction began when(Required)

MM slash DD slash YYYY

Construction Start Date(Required)

MM slash DD slash YYYY

Construction Start Date(Required)

MM slash DD slash YYYY

Flood Needed(Required)

Yes

Mortgage Company

Builders Risk Additional Notes

Cargo

Desired Limits of Liability (Required)

Describe the Cargo Carried(Required)

Bond

Bond Amount(Required)

Bond Additional Notes (Required)

Personal Insurance

Business Insurance

Personal Account Review

Business Account Review

Personal Insurance

Business Insurance

Commercial Fast App – Agent Entered