Jeffrey Steen, CIC, RPLU

Business Insurance Application

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RLIPack® Business Owners Quote Information

  *Proposed Effective Date:

*Named Insured:

*Email:

*Mailing Address:

*City:

*State:

*Zip:

*Phone Number:

*Website:

Sole ProprietorPartnershipCorporationLLC/LLPOther If Other

*Date Firm Established:

*Estimated Annual Revenues:

Current BOP Carrier:

*Professional Liability Coverage: *Current Professional Liability Coverage:

*Effective/Expiration Dates:

*Limits:

*Loss History: No losses5 year loss runs attached.Quote subject to acceptable loss history. (Note: Five year loss history is required for binding. If there are no losses, a signed letter from the insured verifying no losses in 5 years is acceptable.) GENERAL LIABILITY COVERAGES *Liability Limits: $500,000 Occurrence / $1,000,000 Aggregate$1,000,000 Occurrence / $2,000,000 Aggregate$2,000,000 Occurrence / $4,000,000 Aggregate Optional Liability Coverages: Hired/Non-owned LiabilityHired Auto Physical DamageEmployee Benefits Liability Employee Benefits Retro Date:

Limit:

PROPERTY COVERAGES *Property Deductible: $500$1,000$2,500$5,000 Increased Property Limits: (The limit shown in parenthesis is included automatically on the policy form.) Accounts Receivable ($250,000):

Employee Dishonesty ($50,000):

ERISA ($100,000):

Valuable Papers ($100,000):

Fine Arts ($100,000):

Surveying / Field / Contractors Equipment:

Number of Employees:

Deductible:

Any other property coverages not listed above: LOCATION INFORMATION *Location Address (If different from mailing): Building Limit:

*Business Contents Limit: (Include value of computer hardware, software, improvements & betterments):

Building Updates: Roof:

Electrical:

Heating:

Plumbing:

*Construction Type: FrameJoisted MasonryNon-CombustibleMasonry Non-CombustibleFire Resistive Occupancy: OwnerTenant *Year Built:

Number Of Stories:

Square Footage:

*Occupied Square Footage:

Operational Sprinkler System: YesNo Central Station Alarm System: Fire: YesNo Burglar: YesNo Additional Interests: Mortgagee, Loss Payee, etc #1 Name:

Address: Interest: #2 Name:

Address: Interest: