(LAVA) Agent Entered Commercial Fast App Agent Name (You)(Required)Doug BenzLiz BenzLouise PhillipsNoah ThiesSamantha HymanName of Business(Required)Website 1st Point of Contact(Required) First Last 1st Point of Contact Email(Required) 1st Point of Contact Office Number(Required)1st Point of Contact Mobile Number(Required)How did you find us?(Required) Referral Google Social Media Other Referral Source(Required)Referred By(Required) First Last Desired Effective Date(Required) MM slash DD slash YYYY Is the first Point of Contact an Owner?(Required) Yes No First Point of Contact Ownership Percentage(Required)Please enter a number from 1 to 100.Owner Name(Required) First Last Owner Email(Required) Percentage of Ownership(Required)Please enter a number from 1 to 100.Are there more Owners?(Required) Yes No Other Owner Name(Required) First Last Other Owner Email(Required) Percentage of Ownership(Required)Please enter a number from 1 to 100.FEIN(Required)Mailing Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is your Physical address same as your mailing address?(Required) Yes No Phsyical Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Entity Type(Required) CORP LLC LP SOLE PROP Others Any Subsidiaries?(Required) Yes No Description of Operations(Required)Years of Experience (Owner)(Required)Please enter a number from 0 to 100.Years in Business(Required)Please enter a number from 0 to 100.Current Insurance Co(Required)Expiration Date(Required) 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 No FileMax. file size: 39 MB. Any Losses Last 5 Years?(Required) Yes No Date, Description, and Estimate of Loss(Required)Do you have a business continuation plan?(Required) Yes No Is it funded?(Required) Yes No Would you like to discuss/review funding plans(Required) Yes No Would you like to learn more about this subject?(Required) Yes No Coverage RequestedCoverage Requested(Required) General Liability Property Auto Workers Comp Errors and Omissions Cyber Directors and Officers Inland Marine Crime Umbrella Group Health Builders Risk Cargo Bond Executive Bonus Plans Other Other Coverage Details(Required)Commercial General LiabilitySquare Footage you occupy or own(Required)Do you Own or Lease your space(Required) Yes No Liability Limits Requested(Required)1MM/2MM2MM/4MMAre you Contractor or General Contractor?(Required) Contractor General Contractor Neither Do you use Sub Contractors?(Required) Yes No 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 10.Any Waivers of Subrogation?(Required) Yes No Description of Work(Required)Do Employees use their own vehicles in the business?(Required) Yes No General Liability Additional NotesCommercial PropertyHow many locations do you own or lease?(Required)Location Information Address Is this a Condo? Occupancy Monitored Alarm Sprinklered Building Value Tenants Improvements and Betterments Business Personal Property Square Feet How many stories Year Built Construction Type/Material Roof Type Year Roof Updated Year Electric Updated Year Plumbing Updated Year HVAC Updated Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Commercial Property Additional NotesCommercial AutoDo you have a Driver List file available for upload(Required)YesNoFileMax. file size: 39 MB. How many drivers do you have?Please enter a number from 1 to 5.Drivers Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. VehiclesDesired Liability Coverage(Required)300,000500,0001,000,0005,000,000Uninsured Motorist(Required)Reject300,000500,0001,000,000Personal Injury Protection(Required)Reject300,000500,0001,000,000Collision & Comp Deductibles(Required)No500 Deductible1000 Deductible2500 DeductibleHired/non‐owned liability(Required) YES NO Rental Reimbursement(Required) YES NO Roadside(Required) YES NO Do any vehicles require "Filings"(Required)YesNoAre all vehicles titled in the name of your business(Required) YES NO Title Variations(Required)Do you have a vehicle list file available to upload(Required) YES NO Vehicle ListMax. file size: 39 MB. How many vehicles(Required)First ChoiceSecond ChoiceThird ChoiceVehicle Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Commericial Auto Additional NotesWorkers CompensationOwner Info Name DOB Title Duties Ownership % Exclude Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Does your business have a documented Safety Program(Required) Yes No File(Required)Max. file size: 39 MB. Employee/Payroll Category(Required)Employee CategoryEmployeesPayroll Category Total Add Remove*Note: Employees Category Examples: Clerical, Driver, Technician, Retail, Electricians, HVAC, Plumbers, Artisan ContractorWorkers Comp Additional NotesErrors and OmmissionsLimits of Liability(Required)1,000,0002,000,0003,000,0004,000,0005,000,000Errors and Ommissions Additional Notes(Required)CyberDesired Limits of Liability(Required)100,000250,000500,0001,000,0002,000,000Cyber Additional Notes(Required)Directors and OfficersDesired Limits(Required)1,000,0002,000,000Directors and Officers Additional Notes(Required)Inland MarineDo you have an Equipment List to upload(Required) Yes No File(Required)Max. file size: 39 MB. List(Required)Item DescriptionSerial #Make/ModelItem Value Add RemoveTotal Estimate Value of Misc. Tools/Equipment ea. item under $500(Required)Example: hammers, drills, bits combined equal $2kInland Marine Addtional NotesCrimeDesired Limits of Liability(Required)100,000250,000500,0001,000,0002,000,000Crime Additional NotesUmbrellaDesired Excess Liability Limits(Required)1,000,0002,000,0003,000,0004,000,0005,000,000Deductible(Required)2,5005,00010,000Umbrella Additional NotesGroup HealthCompany Desired Coverages(Required) Major Medical Dental Vision Life Short Term Disability Long Term Disability Other Ancillary Coverages Other Ancillary Coverages types(Required)We require a Census. Choose your method(Required)Download the Excel File and UploadContinue Completing this formUpload Completed Census(Required)Max. file size: 39 MB. Employee Info Name Date of Birth Gender Work Zip Code Home Zip Code Current Medicare Enrollee Current Cobra Or State Continuation Short Term Disability Long Term Disability Annual Salary + Commissions (If Any) Enrollment Type - Major Medical Enrollment Type - Dental Enrollment Type - Vision Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Does the employee have any dependents?(Required) Yes No Family Relationship Name Date of Birth Home Zip Current Medicare Enrollee Current Cobra Or State Continuation Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Group Health Additional NotesBuilders RiskOwner Name(Required) First Last Builder Name(Required) First Last Are you the Owner or Contractor(Required) Owner Contractor Property Location Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code How Many Buildings At This Location(Required)12345Building details Cost of Labor Cost of Materials Construction Type Roof Type Number of Stories Square Feet Actions Edit Delete There are no Entries. Add Entry Maximum number of entries reached. Inside City Limits(Required) YES NO 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(Required)Has Construction Begun(Required) YES NO Construction began when(Required) MM slash DD slash YYYY Construction Start Date(Required) MM slash DD slash YYYY Expected Completion Date(Required) MM slash DD slash YYYY Flood Needed(Required) YES NO Mortgage Company(Required)Builders Risk Additional NotesCargoDesired Limits of Liability (Required)25,00050,000100,000250,000500,0001,000,000+Describe the Cargo Carried(Required)BondType of Bond(Required)Bond Amount(Required)Bond Additional Notes (Required)
