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Briefly explain the type of business
How long has your company been in business?
Is coverage currently in place?
Yes
No
If not please explain why
Approximately how many insurance certificates (ie. COI’s) do you require annually?
Do you have any special insurance requirements (ie. Additional Insured designations, Waiver of Subrogation etc.)
Yes
No
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Are you currently operating without insurance
Yes
No
If so please explain why
Any prior claims?
Has any current/previous policy been cancelled or non-renewed within the last 5 years?
Yes
No
If so please explain why
How many physical locations does the business have?
Please list the city/state for each location
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