Business name:

Doing Business As:

Primary address:

Desired policy effective date:

Legal entity type:
—Please choose an option—IndividualCorporationPartnershipsLimited Liability CorporationLimited Liability Partnership

Year started:

Federal ID number:

Primary phone:

Business email:

Website:

Annual revenue:

Total number of locations:

Full time:

Part time:

Seasonal:

Does applicant want building coverage?
—Please choose an option—NoYes

Business personal property limit:

$

Occupancy type:
—Please choose an option—Commercial TenantCondominium Unit Owner

What percentage of the building does the applicant occupy?

Type of Business

Classification:
—Please choose an option—Beauty Parlors and Hair SalonBarbershopNail SalonMobile stylists and booth/chairs rentersBarber or Beauty Shop Supplies DistributorsCosmetics, Hair or Skin Preparation

Loss History

Has the applicant had losses in the past five years?
—Please choose an option—NoYes

Number of stories:

Total square footage:

Year built:

Is the building sprinklered?
—Please choose an option—NoYes

Liability limit per occurrence:
—Please choose an option—$1,000,000 (default)$2,000,000$500,000

Preferred Contact Method

Preferred Contact MethodPhoneTextEmail

Is applicant interested in seeing pricing for the following options?

Workplace violence coverage endorsement —Please choose an option—NoYes

Commercial risk cyber risk coverage endorsement —Please choose an option—NoYes

Employee benefits liability —Please choose an option—NoYes

Employment practices liability coverage —Please choose an option—NoYes