Applicant Information:

*Owner's Name:

*Business Name:

Entity:  Corp. LLC Sole Prop. Non-Profit

*Work Telephone #:

    Alternative Telephone #: 

Fax Telephone #:

Email Address:

*Mailing Address:

*City, State, Zip Code:

      County:  Select county NONE - INDEPENDENT CITY Accomack Albemarle Alleghany Amelia Amherst Appomattox Arlington Augusta Bath Bedford Bland Botetourt Brunswick Buchanan Buckingham Campbell Caroline Carroll Charles City Charlotte Chesterfield Clarke Craig Culpeper Cumberland Dickenson Dinwiddie Essex Fairfax Fauquier Floyd Fluvanna Franklin Frederick Giles Gloucester Goochland Grayson Greene Greensville Halifax Hanover Henrico Henry Highland Isle Of Wight James City King And Queen King George King William Lancaster Lee Loudoun Louisa Lunenburg Madison Mathews Mecklenburg Middlesex Montgomery Nelson New Kent Northampton Northumberland Nottoway Orange Page Patrick Pittsylvania Powhatan Prince Edward Prince George Prince William Pulaski Rappahannock Richmond Roanoke Rockbridge Rockingham Russell Scott Shenandoah Smyth Southampton Spotsylvania Stafford Surry Sussex Tazewell Warren Washington Westmoreland Wise Wythe York

*FEIN#/SSN#:

Has The Owner Ever Filed Bankruptcy? Yes No   

Has The Owner Ever Been Arrested For Any Reason?  Yes No

*Class of Business:

*Brief Description Of What Your Business Does:

*Years In Business:

  Owner's Years Of Experience: 

*Annual Gross Sales/Receipts:

  Annual Gross Payroll:    Owner's Payroll: 

*Number Of Employees:

Annual Sub-Contractors Cost:

  Do You Require Certificates Of Insurance?  Yes No

Current Carrier Information:

*Current Insurance Company:

  None: 

Current Expiration Date:

*Prior Claims (5 Years):

Yes No

    If Yes, please explain:

Has Any Policy Been Cancelled For Non-Payment Of Premium?  Yes No

General Liability Information:

*Liability Limit Requested:

SELECT LIABILITY LIMIT $1,000,000 / $2,000,000 $2,000,000 / $4,000,000 $2,000,000 / $6,000,000   Umbrella Coverage:  SELECT LIABILITY LIMIT NOT REQUESTED $1,000,000 $2,000,000 $3,000,000 $4,000,000 $5,000,000

Liability Deductible:

SELECT LIABILITY DEDUCTIBLE NONE $250 $500 $1,000 $2,500

Hired/Non-Owned Auto:

SELECT DO NOT INCLUDE INCLUDE WITH GENERAL LIABILITY LIMITS INCLUDE WITH AUTO LIABILITY LIMITS

Business Personal Property Information:  (Do Not Include Company Vehicles)

Do Not Quote

Business Property Value:

Equipment Value:

Tools Value:

Deductible:

SELECT DEDUCTIBLE NONE $100 $250 $500 $1,000 $2,500

Building Information:

Does The Business Own/Lease Building?   Own Lease Home

Deductible:

SELECT DEDUCTIBLE NONE $100 $250 $500 $1,000 $2,500 $5,000

Does Your Business Have More Than One Location?:

Yes No 

If So, We Will Contact You For Other Location Information.

Please Complete This Section For Your First Location.

Current Insured Building Value:

(Answer Only If Your Business Owns)

Year Building Was Built:

    Flood Insurance Requested:  Yes No

Has There Been Any Updates?

No Updates

Plumbing: (Year)    Electrical: (Year)    Heating: (Year)

Building Square Footage:

Square Footage Occupied:

Are There Any Other Occupants?

Yes No

 If So, What Types Of Businesses?

Building Construction Type:

Frame Brick/Masonry Metal/Steel Stucco

Roof Type:

Asphalt Shingle Metal Slate Cedar Tar/Stone (Flat Roof)

Distance To Nearest Fire House:

(Miles)

Distance To Fire Hydrant:

(Feet)

Does The Building Have Any Of The Following Protection Devices?

Security System  Fire Alarm  Security Guard  Security Dog 

Fire Extinguishers  Outside Flood Lights  Fence Around Property

Commercial Automobile:

Do Not Quote

Liability Limits Requested:

SELECT LIABILITY LIMIT $100,000 CSL $300,000 CSL $500,000 CSL $750,000 CSL $1,000,000 CSL CSL= Combined Single Limit

Comprehensive Deductible:

SELECT DEDUCTIBLE NONE $0 $100 $250 $500 $1,000 $2,500 $5,000

Collision Deductible:

SELECT DEDUCTIBLE NONE $100 $250 $500 $1,000 $2,500 $5,000   Rental/Towing: 

Hired/Non-Owned Auto:

SELECT DO NOT INCLUDE INCLUDE WITH LIABILITY LIMITS

Vehicle #1: 

Liability Only

Year:    Make:    Model:    VIN #:

Vehicle #2: 

Liability Only

Year:    Make:    Model:    VIN #:

Vehicle #3: 

Liability Only

Year:    Make:    Model:    VIN #:

Vehicle #4: 

Liability Only

Year:    Make:    Model:    VIN #:

Vehicle #5: 

Liability Only

Year:    Make:    Model:    VIN #:

Applicant Information:

*Owner's Name:

*Business Name:

Entity:  Corp. LLC Sole Prop. Non-Profit

*Work Telephone #:

    Alternative Telephone #: 

Fax Telephone #:

Email Address:

*Mailing Address:

*City, State, Zip Code:

      County:  Select county NONE - INDEPENDENT CITY Accomack Albemarle Alleghany Amelia Amherst Appomattox Arlington Augusta Bath Bedford Bland Botetourt Brunswick Buchanan Buckingham Campbell Caroline Carroll Charles City Charlotte Chesterfield Clarke Craig Culpeper Cumberland Dickenson Dinwiddie Essex Fairfax Fauquier Floyd Fluvanna Franklin Frederick Giles Gloucester Goochland Grayson Greene Greensville Halifax Hanover Henrico Henry Highland Isle Of Wight James City King And Queen King George King William Lancaster Lee Loudoun Louisa Lunenburg Madison Mathews Mecklenburg Middlesex Montgomery Nelson New Kent Northampton Northumberland Nottoway Orange Page Patrick Pittsylvania Powhatan Prince Edward Prince George Prince William Pulaski Rappahannock Richmond Roanoke Rockbridge Rockingham Russell Scott Shenandoah Smyth Southampton Spotsylvania Stafford Surry Sussex Tazewell Warren Washington Westmoreland Wise Wythe York

*FEIN#/SSN#:

Has The Owner Ever Filed Bankruptcy? Yes No   

Has The Owner Ever Been Arrested For Any Reason?  Yes No

*Class of Business:

*Brief Description Of What Your Business Does:

*Years In Business:

  Owner's Years Of Experience: 

*Annual Gross Sales/Receipts:

  Annual Gross Payroll:    Owner's Payroll: 

*Number Of Employees:

Annual Sub-Contractors Cost:

  Do You Require Certificates Of Insurance?  Yes No

Current Carrier Information:

*Current Insurance Company:

  None: 

Current Expiration Date:

*Prior Claims (5 Years):

Yes No

    If Yes, please explain:

Has Any Policy Been Cancelled For Non-Payment Of Premium?  Yes No

General Liability Information:

*Liability Limit Requested:

SELECT LIABILITY LIMIT $1,000,000 / $2,000,000 $2,000,000 / $4,000,000 $2,000,000 / $6,000,000   Umbrella Coverage:  SELECT LIABILITY LIMIT NOT REQUESTED $1,000,000 $2,000,000 $3,000,000 $4,000,000 $5,000,000

Liability Deductible:

SELECT LIABILITY DEDUCTIBLE NONE $250 $500 $1,000 $2,500

Hired/Non-Owned Auto:

SELECT DO NOT INCLUDE INCLUDE WITH GENERAL LIABILITY LIMITS INCLUDE WITH AUTO LIABILITY LIMITS

Business Personal Property Information:  (Do Not Include Company Vehicles)

Do Not Quote

Business Property Value:

Equipment Value:

Tools Value:

Deductible:

SELECT DEDUCTIBLE NONE $100 $250 $500 $1,000 $2,500

Building Information:

Does The Business Own/Lease Building?   Own Lease Home

Deductible:

SELECT DEDUCTIBLE NONE $100 $250 $500 $1,000 $2,500 $5,000

Does Your Business Have More Than One Location?:

Yes No 

If So, We Will Contact You For Other Location Information.

Please Complete This Section For Your First Location.

Current Insured Building Value:

(Answer Only If Your Business Owns)

Year Building Was Built:

    Flood Insurance Requested:  Yes No

Has There Been Any Updates?

No Updates

Plumbing: (Year)    Electrical: (Year)    Heating: (Year)

Building Square Footage:

Square Footage Occupied:

Are There Any Other Occupants?

Yes No

 If So, What Types Of Businesses?

Building Construction Type:

Frame Brick/Masonry Metal/Steel Stucco

Roof Type:

Asphalt Shingle Metal Slate Cedar Tar/Stone (Flat Roof)

Distance To Nearest Fire House:

(Miles)

Distance To Fire Hydrant:

(Feet)

Does The Building Have Any Of The Following Protection Devices?

Security System  Fire Alarm  Security Guard  Security Dog 

Fire Extinguishers  Outside Flood Lights  Fence Around Property

Commercial Automobile:

Do Not Quote

Liability Limits Requested:

SELECT LIABILITY LIMIT $100,000 CSL $300,000 CSL $500,000 CSL $750,000 CSL $1,000,000 CSL CSL= Combined Single Limit

Comprehensive Deductible:

SELECT DEDUCTIBLE NONE $0 $100 $250 $500 $1,000 $2,500 $5,000

Collision Deductible:

SELECT DEDUCTIBLE NONE $100 $250 $500 $1,000 $2,500 $5,000   Rental/Towing: 

Hired/Non-Owned Auto:

SELECT DO NOT INCLUDE INCLUDE WITH LIABILITY LIMITS

Vehicle #1: 

Liability Only

Year:    Make:    Model:    VIN #:

Vehicle #2: 

Liability Only

Year:    Make:    Model:    VIN #:

Vehicle #3: 

Liability Only

Year:    Make:    Model:    VIN #:

Vehicle #4: 

Liability Only

Year:    Make:    Model:    VIN #:

Vehicle #5: 

Liability Only

Year:    Make:    Model:    VIN #: