Business Owners Package Expanded Form

What is your first name? **
What is your first name? *
What is your last name? **
What is your last name? *
What is your phone number? **
What is your phone number? *
What is your email? **
What is your email? *
What is your company's name? **
What is your company's name? *
Please provide a brief description of your business operations. **
Please provide a brief description of your business operations. *
What is your role?
What is your role?
- Owner
- Manager
- Other
Please provide a description of your role.
Please provide a description of your role.
What is the primary mailing address for the company? **
What is the primary mailing address for the company? *

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Company Entity Type
What is the entity type of your company?
- Sole Proprietor
- Partnership / LLP
- Corporation
- LLC
- PC
- Other
Entity Type Other?
What is the entity type for the company?
Please enter your Federal Identification Number (FEIN)? **
Please enter your Federal Identification Number (FEIN)? *
Is there more than one owner?
Is there more than one owner?
- Yes
- No
Please list the members/owners/officers along with their respective ownership interests:
Please list the members/owners/officers along with their respective ownership interests:
Owner/Member/Officer Full Name Ownership Percentage (50%)
What year was the company established?
What year was the company established? (YYYY)
What is your website address?
What is your website address?
What date would you like coverage to begin? **
What date would you like coverage to begin? *
MM slash DD slash YYYY
Excluding computers and media equipment, what is the approximate value of the business personal property owned by the company? (Office furniture, copiers, inventory, tools, etc...)
Excluding computers and media equipment, what is the approximate value of the business personal property owned by the company? (Office furniture, copiers, inventory, tools, etc...)
What is the value of the computers & media equipment owned by the company?
What is the value of the computers & media equipment owned by the company?
What are the company's annual gross receipts?
What are the company's annual gross receipts?
How many locations does the company have? **
How many locations does the company have? *
Location #1
Do you own or lease this location? **
Do you own or lease this location? *
- Own
- Lease
What is the value of the improvements and betterments made to the leased location(s)?
What is the value of the improvements and betterments made to the leased location(s)?
What is the legal name of the owner of the building?**
What is the legal name of the owner of the building?*
Check this box if this location's address is the same as your primary address entered above.
Check this box if this location's address is the same as your primary address entered above.
- Click here
What is the address of the location for which you are providing information?**
What is the address of the location for which you are providing information?*

Street Address Address Line 2 City State ZIP Code
Construction
Please select this building's construction type.
Please select the building's construction type.
- A - Fireproof Steel Frame
- B - Reinforced Concrete/Non-Combustible
- C - Masonry Construction/Wood Roof
- D - All Combustible (Wood Frame)
- S - Pre-engineered/Steel
- U - Unknown
Please select the term that best describes the condition of the building.
Please select the term that best describes the condition of the building.
- Excellent
- Very Good
- Good
- Average
- Fair
- Poor
Please select the term that best describes the quality of the building.
Please select the term that best describes the quality of the building.
- Excellent
- Good
- Average
- Low
What construction material was used for the walls?
What construction material was used for the walls?
- Brick
- Poured Concrete
- Brick Veneer
- Frame
- Hollow Block (Brick Faced)
- Metal Clad
- All Metal
What year was the electrical wiring last updated? (YYYY)
What year was the electrical wiring last updated? (YYYY)
Was the electrical wiring update partial or complete?
Was the electrical wiring update partial or complete?
- Partial
- Complete
What year was the plumbing system last updated? (YYYY)
What year was the plumbing system last updated? (YYYY)
Was the plumbing system update partial or complete?
Was the plumbing system update partial or complete?
- Partial
- Complete
What year was the heating system last updated? (YYYY)
What year was the heating system last updated? (YYYY)
Was the heating system update partial or complete?
Was the heating system update partial or complete?
- Partial
- Complete
What type of heating system does the building have?
What type of heating system does the building have?
- Forced Air
- Window Unit
- Wall Unit
What year was the cooling system last updated? (YYYY)
What year was the cooling system last updated? (YYYY)
Was the cooling system update partial or complete?
Was the cooling system update partial or complete?
- Partial
- Complete
What type of cooling system does the building have?
What type of cooling system does the building have?
- Forced Air
- Window Unit
- Wall Unit
What type of fuel does the heating/AC system utilize?
What type of fuel does the heating/AC system utilize?
- Electric
- Gas
- Oil
- Diesel
- Solar
What year was the roof last updated? (YYYY)
What year was the roof last updated? (YYYY)
Was the roof update partial or complete?
Was the roof update partial or complete?
- Partial
- Complete
What is this building's roof type?
What is this building's roof type?
Please enter the building's roof type.
Please enter the building's roof type.
Does the building have a basement?
Does the building have a basement?
- Yes
- No
Does the building have an attic/penthouse?
Does the building have an attic/penthouse?
- Yes
- No
What year was the building built? (YYYY)
What year was the building built? (YYYY)
Has the building been gut renovated since its was built?
Has the building been gut renovated since its was built?
- Yes
- No
- Not sure
What year was the building renovated? (YYYY)
What year was the building renovated? (YYYY)
What is the floor height? (In feet)
What is the floor height? (In feet)
How many floors/stories does the building have?
How many floors/stories does the building have?
What is the total square footage of the building?
What is the total square footage of the building?
What is the square footage of the space your company occupies in this building?
What is the square footage of the space your company occupies in this building?
What is the value of the building?
What is the value of the building?
What is the replacement cost of the building?
What is the replacement cost of the building?
What is the value of the contents within the building?
What is the value of the contents within the building?
Occupancy Classification
What is the occupancy classification of the building?
What is the occupancy classification of the building?
Please enter the occupancy classification of this building.
Please enter the occupancy classification of this building.
Do any other tenants occupy this building?
Do any other tenants occupy this building?
- Yes
- No
How many tenants occupy this building? (Not including your company.)
How many tenants occupy this building? (Not including your company.)
What is the square footage of the space your company occupies in this building?
What is the square footage of the space your company occupies in this building?
Please provide a description of the other occupancies at this location.
Please provide a description of the other occupancies at this location.
Protection Features
Is the building equipped with fire extinguishers?
Is the building equipped with fire extinguishers?
- Yes
- No
Is the building's inspection current?
Is the building's inspection current?
- Yes
- No
Does the building have a manual pull box fire alarm system?
Does the building have a manual pull box fire alarm system?
- Yes
- No
Is the manual pull box fire alarm being monitored/supervised?
Is the manual pull box fire alarm being monitored/supervised?
- Yes
- No
Does the building have sprinkler protection?
Does the building have sprinkler protection?
- Yes
- No
What percentage of the building is sprinklered?
What percentage of the building is sprinklered?
Is the sprinkler system being monitored/supervised?
Is the sprinkler system being monitored/supervised?
- Yes
- No
Does the building have smoke/heat detectors?
Does the building have smoke/heat detectors?
- Yes
- No
Are the smoke/heat detectors being monitored/supervised?
Are the smoke/heat detectors being monitored/supervised?
- Yes
- No
Does the building have a security system?
Does the building have a security system?
- Yes
- No
Is the security system being monitored/supervised?
Is the security system being monitored/supervised?
- Yes
- No
Does the building have fire hydrants within 1,000 feet?
Does the building have fire hydrants within 1,000 feet?
- Yes
- No
Does the building have a fire department within five miles?
Does the building have a fire department within five miles?
- Yes
- No
Exposures
Is the building located in a severe hazard flood zone? (I.e. A, V, etc.)
Is the building located in a severe hazard flood zone? (I.e. A, V, etc.)
- Yes
- No
Is the building located in a high wind prone area? (I.e. coastal)
Is the building located in a high wind prone area? (I.e. coastal)
- Yes
- No
Does the building have any special hazards that could impact it? (I.e. Earthquake, etc.)
Does the building have any special hazards that could impact it? (I.e. Earthquake, etc.)
- Yes
- No
Please provide a brief description of the special hazards that could impact this building.
Please provide a brief description of the special hazards that could impact this building.
Please select the term that best describes this building's exposure to risk of physical damage.
Please select the term that best describes this building's exposure to risk of physical damage.
- Low
- Moderate
- Severe
Location #2
Do you own or lease this location? *
Do you own or lease this location? *
- Own
- Lease
What is the value of the improvements and betterments made to the leased location(s)? 2
What is the value of the improvements and betterments made to the leased location(s)?
What is the legal name of the owner of the building?**
What is the legal name of the owner of the building?*
What is the address of the location for which you are providing information?**
What is the address of the location for which you are providing information?*

Street Address Address Line 2 City State ZIP Code
Construction
Please select this building's construction type.
Please select the building's construction type.
- A - Fireproof Steel Frame
- B - Reinforced Concrete/Non-Combustible
- C - Masonry Construction/Wood Roof
- D - All Combustible (Wood Frame)
- S - Pre-engineered/Steel
- U - Unknown
Please select the term that best describes the condition of the building.
Please select the term that best describes the condition of the building.
- Excellent
- Very Good
- Good
- Average
- Fair
- Poor
Please select the term that best describes the quality of the building.
Please select the term that best describes the quality of the building.
- Excellent
- Good
- Average
- Low
What construction material was used for the walls?
What construction material was used for the walls?
- Brick
- Poured Concrete
- Brick Veneer
- Frame
- Hollow Block (Brick Faced)
- Metal Clad
- All Metal
What year was the electrical wiring last updated? (YYYY)
What year was the electrical wiring last updated? (YYYY)
Was the electrical wiring update partial or complete?
Was the electrical wiring update partial or complete?
- Partial
- Complete
What year was the plumbing system last updated? (YYYY)
What year was the plumbing system last updated? (YYYY)
Was the plumbing system update partial or complete?
Was the plumbing system update partial or complete?
- Partial
- Complete
What year was the heating system last updated? (YYYY)
What year was the heating system last updated? (YYYY)
Was the heating system update partial or complete?
Was the heating system update partial or complete?
- Partial
- Complete
What type of heating system does the building have?
What type of heating system does the building have?
- Forced Air
- Window Unit
- Wall Unit
What year was the cooling system last updated? (YYYY)
What year was the cooling system last updated? (YYYY)
Was the cooling system update partial or complete?
Was the cooling system update partial or complete?
- Partial
- Complete
What type of cooling system does the building have?
What type of cooling system does the building have?
- Forced Air
- Window Unit
- Wall Unit
What type of fuel does the heating/AC system utilize?
What type of fuel does the heating/AC system utilize?
- Electric
- Gas
- Oil
- Diesel
- Solar
What year was the roof last updated? (YYYY)
What year was the roof last updated? (YYYY)
Was the roof update partial or complete?
Was the roof update partial or complete?
- Partial
- Complete
What is this building's roof type?
What is this building's roof type?
Please enter the building's roof type.
Please enter the building's roof type.
Does the building have a basement?
Does the building have a basement?
- Yes
- No
Does the building have an attic/penthouse?
Does the building have an attic/penthouse?
- Yes
- No
What year was the building built? (YYYY)
What year was the building built? (YYYY)
Has the building been gut renovated since its was built?
Has the building been gut renovated since its was built?
- Yes
- No
- Not sure
What year was the building renovated? (YYYY)
What year was the building renovated? (YYYY)
What is the floor height? (In feet)
What is the floor height? (In feet)
How many floors/stories does the building have?
How many floors/stories does the building have?
What is the total square footage of the building?
What is the total square footage of the building?
What is the square footage of the space your company occupies in this building?
What is the square footage of the space your company occupies in this building?
What is the value of the building?
What is the value of the building?
What is the replacement cost of the building?
What is the replacement cost of the building?
What is the value of the contents within the building?
What is the value of the contents within the building?
Occupancy Classification
What is the occupancy classification of the building? 2
What is the occupancy classification of the building?
Please enter the occupancy classification of this building.
Please enter the occupancy classification of this building.
Do any other tenants occupy this building? 2
Do any other tenants occupy this building?
- Yes
- No
How many tenants occupy this building? (Not including your company.)
How many tenants occupy this building? (Not including your company.)
What is the square footage of the space your company occupies in this building?
What is the square footage of the space your company occupies in this building?
Please provide a description of the other occupancies at this location.
Please provide a description of the other occupancies at this location.
Protection Features
Is the building equipped with fire extinguishers?
Is the building equipped with fire extinguishers?
- Yes
- No
Is the building's inspection current?
Is the building's inspection current?
- Yes
- No
Does the building have a manual pull box fire alarm system?
Does the building have a manual pull box fire alarm system?
- Yes
- No
Is the manual pull box fire alarm being monitored/supervised?
Is the manual pull box fire alarm being monitored/supervised?
- Yes
- No
Does the building have sprinkler protection?
Does the building have sprinkler protection?
- Yes
- No
What percentage of the building is sprinklered?
What percentage of the building is sprinklered?
Is the sprinkler system being monitored/supervised?
Is the sprinkler system being monitored/supervised?
- Yes
- No
Does the building have smoke/heat detectors? 2
Does the building have smoke/heat detectors?
- Yes
- No
Are the smoke/heat detectors being monitored/supervised?
Are the smoke/heat detectors being monitored/supervised?
- Yes
- No
Does the building have a security system?
Does the building have a security system?
- Yes
- No
Is the security system being monitored/supervised?
Is the security system being monitored/supervised?
- Yes
- No
Does the building have fire hydrants within 1,000 feet?
Does the building have fire hydrants within 1,000 feet?
- Yes
- No
Does the building have a fire department within five miles?
Does the building have a fire department within five miles?
- Yes
- No
Exposures
Is the building located in a severe hazard flood zone? (I.e. A, V, etc.)
Is the building located in a severe hazard flood zone? (I.e. A, V, etc.)
- Yes
- No
Is the building located in a high wind prone area? (I.e. coastal)
Is the building located in a high wind prone area? (I.e. coastal)
- Yes
- No
Does the building have any special hazards that could impact it? (I.e. Earthquake, etc.) 2
Does the building have any special hazards that could impact it? (I.e. Earthquake, etc.)
- Yes
- No
Please provide a brief description of the special hazards that could impact this building.
Please provide a brief description of the special hazards that could impact this building.
Please select the term that best describes this building's exposure to risk of physical damage.
Please select the term that best describes this building's exposure to risk of physical damage.
- Low
- Moderate
- Severe
Location #3
Do you own or lease this location? *
Do you own or lease this location? *
- Own
- Lease
What is the value of the improvements and betterments made to the leased location(s)?
What is the value of the improvements and betterments made to the leased location(s)?
What is the legal name of the owner of the building?**
What is the legal name of the owner of the building?*
What is the address of the location for which you are providing information?**
What is the address of the location for which you are providing information?*

Street Address Address Line 2 City State ZIP Code
Construction
Please select this building's construction type.
Please select the building's construction type.
- A - Fireproof Steel Frame
- B - Reinforced Concrete/Non-Combustible
- C - Masonry Construction/Wood Roof
- D - All Combustible (Wood Frame)
- S - Pre-engineered/Steel
- U - Unknown
Please select the term that best describes the condition of the building.
Please select the term that best describes the condition of the building.
- Excellent
- Very Good
- Good
- Average
- Fair
- Poor
Please select the term that best describes the quality of the building.
Please select the term that best describes the quality of the building.
- Excellent
- Good
- Average
- Low
What construction material was used for the walls?
What construction material was used for the walls?
- Brick
- Poured Concrete
- Brick Veneer
- Frame
- Hollow Block (Brick Faced)
- Metal Clad
- All Metal
What year was the electrical wiring last updated? (YYYY)
What year was the electrical wiring last updated? (YYYY)
Was the electrical wiring update partial or complete?
Was the electrical wiring update partial or complete?
- Partial
- Complete
What year was the plumbing system last updated? (YYYY)
What year was the plumbing system last updated? (YYYY)
Was the plumbing system update partial or complete?
Was the plumbing system update partial or complete?
- Partial
- Complete
What year was the heating system last updated? (YYYY)
What year was the heating system last updated? (YYYY)
Was the heating system update partial or complete?
Was the heating system update partial or complete?
- Partial
- Complete
What type of heating system does the building have?
What type of heating system does the building have?
- Forced Air
- Window Unit
- Wall Unit
What year was the cooling system last updated? (YYYY)
What year was the cooling system last updated? (YYYY)
Was the cooling system update partial or complete?
Was the cooling system update partial or complete?
- Partial
- Complete
What type of cooling system does the building have?
What type of cooling system does the building have?
- Forced Air
- Window Unit
- Wall Unit
What type of fuel does the heating/AC system utilize?
What type of fuel does the heating/AC system utilize?
- Electric
- Gas
- Oil
- Diesel
- Solar
What year was the roof last updated? (YYYY)
What year was the roof last updated? (YYYY)
Was the roof update partial or complete?
Was the roof update partial or complete?
- Partial
- Complete
What is this building's roof type?
What is this building's roof type?
Please enter the building's roof type.
Please enter the building's roof type.
Does the building have a basement?
Does the building have a basement?
- Yes
- No
Does the building have an attic/penthouse?
Does the building have an attic/penthouse?
- Yes
- No
What year was the building built? (YYYY)
What year was the building built? (YYYY)
Has the building been gut renovated since its was built?
Has the building been gut renovated since its was built?
- Yes
- No
- Not sure
What year was the building renovated? (YYYY)
What year was the building renovated? (YYYY)
What is the floor height? (In feet)
What is the floor height? (In feet)
How many floors/stories does the building have?
How many floors/stories does the building have?
What is the total square footage of the building?
What is the total square footage of the building?
What is the square footage of the space your company occupies in this building?
What is the square footage of the space your company occupies in this building?
What is the value of the building?
What is the value of the building?
What is the replacement cost of the building?
What is the replacement cost of the building?
What is the value of the contents within the building?
What is the value of the contents within the building?
Occupancy Classification
What is the occupancy classification of the building? 2
What is the occupancy classification of the building?
Please enter the occupancy classification of this building.
Please enter the occupancy classification of this building.
Do any other tenants occupy this building? 2
Do any other tenants occupy this building?
- Yes
- No
How many tenants occupy this building? (Not including your company.)
How many tenants occupy this building? (Not including your company.)
What is the square footage of the space your company occupies in this building?
What is the square footage of the space your company occupies in this building?
Please provide a description of the other occupancies at this location.
Please provide a description of the other occupancies at this location.
Protection Features
Is the building equipped with fire extinguishers?
Is the building equipped with fire extinguishers?
- Yes
- No
Is the building's inspection current?
Is the building's inspection current?
- Yes
- No
Does the building have a manual pull box fire alarm system?
Does the building have a manual pull box fire alarm system?
- Yes
- No
Is the manual pull box fire alarm being monitored/supervised?
Is the manual pull box fire alarm being monitored/supervised?
- Yes
- No
Does the building have sprinkler protection?
Does the building have sprinkler protection?
- Yes
- No
What percentage of the building is sprinklered?
What percentage of the building is sprinklered?
Is the sprinkler system being monitored/supervised?
Is the sprinkler system being monitored/supervised?
- Yes
- No
Does the building have smoke/heat detectors? 2
Does the building have smoke/heat detectors?
- Yes
- No
Are the smoke/heat detectors being monitored/supervised?
Are the smoke/heat detectors being monitored/supervised?
- Yes
- No
Does the building have a security system?
Does the building have a security system?
- Yes
- No
Is the security system being monitored/supervised?
Is the security system being monitored/supervised?
- Yes
- No
Does the building have fire hydrants within 1,000 feet?
Does the building have fire hydrants within 1,000 feet?
- Yes
- No
Does the building have a fire department within five miles?
Does the building have a fire department within five miles?
- Yes
- No
Exposures
Is the building located in a severe hazard flood zone? (I.e. A, V, etc.)
Is the building located in a severe hazard flood zone? (I.e. A, V, etc.)
- Yes
- No
Is the building located in a high wind prone area? (I.e. coastal)
Is the building located in a high wind prone area? (I.e. coastal)
- Yes
- No
Does the building have any special hazards that could impact it? (I.e. Earthquake, etc.) 2
Does the building have any special hazards that could impact it? (I.e. Earthquake, etc.)
- Yes
- No
Please provide a brief description of the special hazards that could impact this building.
Please provide a brief description of the special hazards that could impact this building.
Please select the term that best describes this building's exposure to risk of physical damage.
Please select the term that best describes this building's exposure to risk of physical damage.
- Low
- Moderate
- Severe
Vehicle Information
Does your company own any vehicles?
Does your company own any vehicles?
- Yes
- No
Please provide vehicle information:
Please provide vehicle information:
Year, Make, Model VIN # Leased/Financed/Owned (L/F/O)
Please provide driver information:
Please provide driver information:
Driver Name License Number License State Date of Birth (DD/MM/YY)
Do any of the employees use their personal autos as part of their job requirements?
Do any of the employees use their personal autos as part of their job requirements?
- Yes
- No
What is the radius of operations (in miles)?
What is the radius of operations (in miles)?
Staff Information
Does the company have any employees?
Does the company have any employees?
- Yes
- No
Employee Information

Employee 1 - Job Description
Please enter a brief job description for the first employee type.
Employee 1 - Class code
Please enter the class code for this employee type as listed on your current Workers' Compensation policy, if convenient.
Employee 1 - Full Time Headcount
How many full time employees have this job description?
Employee 1 - Part Time Headcount
How many part time employees have this job description?
Employee 1 - Estimated Payroll
What is the estimated payroll for the employees with this job description?
Second Employee Type?
Is there a second job description to enter?
- Yes
- No
Employee 2 - Job Description
Please enter a brief job description for the second employee type.
Employee 2 - Class code
Please enter the class code for this employee type as listed on your current Workers' Compensation policy, if convenient.
Employee 2 - Full Time Headcount
How many full time employees have this job description?
Employee 2 - Part Time Headcount
How many part time employees have this job description?
Employee 2 - Estimated Payroll
What is the estimated payroll for the employees with this job description?
Third Employee Type?
Is there a third job description to enter?
- Yes
- No
Employee 3 - Job Description
Please enter a brief job description for the third employee type.
Employee 3 - Class code
Please enter the class code for this employee type as listed on your current Workers' Compensation policy, if convenient.
Employee 3 - Full Time Headcount
How many full time employees have this job description?
Employee 3 - Part Time Headcount
How many part time employees have this job description?
Employee 3 - Estimated Payroll
What is the estimated payroll for the employees with this job description?
Fourth Employee Type?
Is there a fourth job description to enter?
- Yes
- No
Employee 4 - Job Description
Please enter a brief job description for the fourth employee type.
Employee 4 - Class code
Please enter the class code for this employee type as listed on your current Workers' Compensation policy, if convenient.
Employee 4 - Full Time Headcount
How many full time employees have this job description?
Employee 4 - Part Time Headcount
How many part time employees have this job description?
Employee 4 - Estimated Payroll
What is the estimated payroll for the employees with this job description?
Has your employee payroll changed dramatically over the course of the last 12 months?
Has your employee payroll changed dramatically over the course of the last 12 months?
- Yes
- No
Please provide a brief description of the reason for the change in payroll. (I.e. New employees, etc.)
Please provide a brief description of the reason for the change in payroll. (I.e. New employees, etc.)
Do you allow employees to use your personal vehicle for business use?
Do you allow employees to use your personal vehicle for business use?
- Yes
- No
What is the projected payroll for the next 12 months?
What is the projected payroll for the next 12 months?
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Coverage for Partners, Officers, or Relatives

Do you want to include/exclude Partners, Officers, Owners, or Relatives from workers compensation coverage?
Do you want to INCLUDE/EXCLUDE Partners, Officers, Owners, or Relatives from workers compensation coverage?
- Include
- Exclude
Please select the individuals you would like to EXCLUDE from workers compensation coverage.
Please select the individuals you would like to EXCLUDE from workers compensation coverage.
- Partner(s)
- Officer(s)
- LLC Member(s)
- Owner(s)
- Relative(s)
Please select the individuals you would like to INCLUDE in workers compensation coverage.
Please select the individuals you would like to INCLUDE in workers compensation coverage.
- Partner(s)
- Officer(s)
- LLC Member(s)
- Owner(s)
- Relative(s)
Please enter information about the partner(s) to be EXCLUDED from workers compensation coverage.
Please enter information about the partner(s) to be EXCLUDED from workers compensation coverage.
Full Name Title Duties Date of Birth Compensation Ownership %
Please enter information about the partner(s) to be INCLUDED in workers compensation coverage.
Please enter information about the partner(s) to be INCLUDED in workers compensation coverage.
Full Name Title Duties Date of Birth Compensation Ownership %
Please enter information about the officer(s) to be EXCLUDED from workers compensation coverage.
Please enter information about the officer(s) to be EXCLUDED from workers compensation coverage.
Full Name Title Duties Date of Birth Compensation Ownership %
Please enter information about the officer(s) to be INCLUDED in workers compensation coverage.
Please enter information about the officer(s) to be INCLUDED in workers compensation coverage.
Full Name Title Duties Date of Birth Annual Payroll Ownership %
Please enter information about the LLC Member(s) to be EXCLUDED from workers compensation coverage.
Please enter information about the LLC Member(s) to be EXCLUDED from workers compensation coverage.
Full Name Title Duties Date of Birth Compensation Ownership %
Please enter information about the LLC Member(s) to be INCLUDED in workers compensation coverage.
Please enter information about the LLC Member(s) to be INCLUDED in workers compensation coverage.
Full Name Title Duties Date of Birth Compensation Ownership %
Please enter information about the Owner(s) to be EXCLUDED from workers compensation coverage.
Please enter information about the Owner(s) to be EXCLUDED from workers compensation coverage.
Full Name Title Duties Date of Birth Compensation Ownership %
Please enter information about the Owner(s) to be INCLUDED in workers compensation coverage.
Please enter information about the Owner(s) to be INCLUDED in workers compensation coverage.
Full Name Title Duties Date of Birth Compensation Ownership %
Please enter information about the relative(s) to be EXCLUDED from workers compensation coverage.
Please enter information about the relative(s) to be EXCLUDED from workers compensation coverage.
Full Name Title Duties Date of Birth Compensation Ownership %
Please enter information about the relative(s) to be INCLUDED in workers compensation coverage.
Please enter information about the relative(s) to be INCLUDED in workers compensation coverage.
Full Name Title Duties Date of Birth Compensation Ownership %
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Subcontractor Utilization

Subcontractor Utilization?
Does your business utilize subcontractors?
- Yes
- No
Subcontractor Percentage of Work
What is the approximate percentage of work that is done by subcontractors? (Ex. 25%)
Subcontractor Certificates of Insurance
Is any work sublet without a certificate of insurance from the contractor?
- Yes
- No
Subcontractor Payroll without Certificates of Insurance
What is the payroll for the subcontractors you do not collect certificates of insurance from?
Do you use written contracts with all subcontractors?
Do you use written contracts with all subcontractors?
- Yes
- No
This field is hidden when viewing the form
Claims Information
Have there been any claims in the past three years? **
Have there been any claims in the past three years? *
- Yes
- No
Please provide a description of any claims from the past three years.
Please provide a description of any claims from the past three years.
Approximate Date (MM/YY) Claim Description Amount Paid ($)
Documents and Comments
Please use this field to upload any relevant insurance documents. (I.e. Current policy declarations pages, appraisals, etc...)
Please use this field to upload any relevant insurance documents. (I.e. Current policy declarations pages, appraisals, etc...)
Drop files here or

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Please enter any additional remarks in the space below.
Please enter any additional remarks in the space below.
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How did you hear about us?
Please share who referred you to us.
Please share who referred you to us.
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Please share how you heard about us.
Consent*
Disclaimer: This online questionnaire is a tool used to gather information. It is not an application for insurance. No insurance coverage will be bound or put into effect by submitting this form.

Consumer disclosure: By checking the box below you authorize the Agency who supplied this form to you to contact you via phone, email, and text messaging; to save and share with business partners the information you provided; to obtain consumer reports that may include credit-based reports (where legally allowed), public records, claims history, and driving records so that they can give you accurate insurance quotes. *
I agree*

Marcella Pitt

Marcella is a Senior New Business Analyst with Ericson Insurance Advisors.

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Business Owners Package Expanded Form

Location #1

Construction

Occupancy Classification

Protection Features

Exposures

Location #2

Construction

Occupancy Classification

Protection Features

Exposures

Location #3

Construction

Occupancy Classification

Protection Features

Exposures

Vehicle Information

Staff Information

Employee Information

Coverage for Partners, Officers, or Relatives

Subcontractor Utilization

Claims Information

Documents and Comments

Marcella Pitt

RiskRevu^TM Newsletter

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Owner/Member/Officer Full Name	Ownership Percentage (50%)

Year, Make, Model	VIN #	Leased/Financed/Owned (L/F/O)

Driver Name	License Number	License State	Date of Birth (DD/MM/YY)

Full Name	Title	Duties	Date of Birth	Compensation	Ownership %

Business Owners Package Expanded Form

Location #1

Construction

Occupancy Classification

Protection Features

Exposures

Location #2

Construction

Occupancy Classification

Protection Features

Exposures

Location #3

Construction

Occupancy Classification

Protection Features

Exposures

Vehicle Information

Staff Information

Employee Information

Coverage for Partners, Officers, or Relatives

Subcontractor Utilization

Claims Information

Documents and Comments

Marcella Pitt

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RiskRevuTM Newsletter

Contact

RiskRevu^TM Newsletter