Applicant's Information

    
In Business for  Years   or New # Yrs Experience Coverage Effective Date    

Agent's Information

General Information (Select all that Apply)

24hr. Operations Consultant Manufacturing Seasonal Operations
Auto Body Shop Computer Consultant/Web/Tech Manufacturers Rep Seasonal Tent / Lot
Auto Repair Deli/Convenience Store Office - Professional Services
Church Habitational Restaurants or Catering Vendor - Fair/Show/Mall/Flea Mkt
Commercial Real Estate In Home Business Retail Wholesale
   
Yes No Hired to perform any:
                                    Cleaning, Installation, Landscaping, Janitorial
                                    or any other type of Contracting work 		Describe Other Operations

Contractor's Operations (Should Total 100%)

% Air Conditioning
Licensed Yes No
LPG work Yes No
Boiler work Yes No
% Appliance Installation/Service
% Awning Install / Service / Repair
Any work above 1st floor Yes No
Describe  
% Blacksmithing
% Carpentry
Inside Buildings % vs. % Outside Buildings
% Carpet Cleaning
% Cabinet Making / Install
% Chimney Cleaning
% Concrete Construction – Incl. Foundations
% Door, Window, Installation / Repair
% Drilling Water
% Driveway Paving
% Drywall
% Electrical
Licensed Yes No
More than 5% of work Performed Outdoors Yes No
Alarm or Video Security Work Yes No
% Fence Install
% Flooring
Carpet %
Hardwood %
Tile %
Vinyl / Linoleum %
Any Hardwood Floor Refinishing Yes No
% Fire Extinguishers Service, Refill, Test
% Garage Door Install / Service / Repair
% Glaziers
% Grading of Land
% Heating
Licensed Yes No
LPG work Yes No
Boiler work Yes No
% Home Theater Install
% Inspection / Appraisal Work
% Interior Decorator
% Janitorial
Floor Waxing Yes No
% Landscaping
Backhoe work Yes No
Tree Pruning, involving Climbing Yes No
Stump Removal Yes No
Spraying Yes No
(if Yes to Spraying)
Greater than 25% of receipts		 Yes No
% Land Surveyor
% Lawn Sprinklers
% Logging and Lumbering
% Masonry - NOT Driveway / Patio / Sidewalk
Chimney work Yes No
Backhoe work Yes No
Foundation work Yes No
(If Yes To Foundation work)
Pouring Only		 Yes No
Digging depth, deeper than 3 ft Yes No
Street / Road work performed Yes No
% Masonry - for Driveway / Patio / Sidewalk
% Painting Exterior
% Painting Interior
% Plumbing
Licensed Yes No
Electric Snaking of Pipe more than 5% of Sales Yes No
Exterior Sewer or Septic work Yes No
LPG work Yes No
Boiler work Yes No
Fire Sprinklers Yes No
Below Grade work Yes No
Digging Depth, deeper than 3 ft Yes No
More than 5% of work Performed Outdoors Yes No
% Pool Install & Maintenance
% Power Washing
% Refrigeration Equipment Install / Service / Repair
% Roofing
Incidental, as respects other work
being performed		 Yes No
New Roofing Yes No
Replacement / Tear-Off Roofing Yes No
Hot Tar Yes No
% Septic Tank, Installation/Service/Repair
% Sewer Cleaning
% Sheet Metal Work Outside
% Siding
Aluminum / Vinyl %
Masonry / Stone %
% Sign Erection, Installation or Repair
% Sign Painting or Lettering Outside
% Snow Removal
% Solar Energy Contractors
% Telephone / Communications Equipment & Cable Installation
% Tents or Canvas Goods Erection
% Tile or Stonework
% Tree Pruning
% Upholstery Work
% Wallpaper Hanging
% Window Cleaning (3 Story Maximum)
% Woodworking
% Other
======
    is the TOTAL PERCENTAGE (All Operations Should Total 100%)
Finished Totaling Contractor's Operations
Add or Change Contractor's Operations

General Information - CONTRACTORS (Select all that Apply)

Commercial Work in Offices % 
vs Other Commercial Work % 
vs  Residential Work % 
Exterior Work Above 3 Stories    Yes No
Cranes    Yes No
EIFS or Asbestos Work Yes No
Medical or Life Support Yes No
More than 5% of work outside of "Home State" Yes No
List additional states   

General Liability Limits


Yes No   Non-Owned & Hired Automobile Liability
(This coverage may not be available via BUTWIN for this prospect)
(Please check our proposal to determine if the coverage has been included, and the premium charged)

Umbrella

 

Include total limit (General Liability + Umbrella) In the "General Liability" section above

List Underlying Insurance

     If this section is not completed, the Umbrella may only be excess over the General Liability Insurance
Commercial Automobile
Insurance Carrier
Policy #
Policy Period
Auto Liablility Premuim $
Auto Liablility Limit

 Yes No
NAMED INSURED on Commercial
 Auto Policy includes names
 not listed on this application
List Names
Workers Compensation
Insurance Carrier
Policy #
Policy Period
Premuim $
Limits

 Yes No
NAMED INSURED on Commercial
 Auto Policy includes names
 not listed on this application
 List Names
 
    # of vehicles
   Year / Make / Model
   Year / Make / Model
   Year / Make / Model
   Year / Make / Model
   Year / Make / Model
   Year / Make / Model
   Year / Make / Model
   Year / Make / Model
   Year / Make / Model
   Year / Make / Model
   
   
      

"Other" Liability coverages
  Describe

Payroll, Sales, and Employee Count

ANNUAL NUMBERS

  
# of Owners Owners Payroll $  
# of Clerical Clerical Payroll $  
# of All Other Full Time Employees
 All Other Payroll $
(Full Time + Part Time)		  
# of All Other Part Time Employees Gross Receipts $  
% of Total Sales from Internet    %
Does the insured hire subcontractors Yes No Cost Of Subcontractors
 Describe Subcontracted Work

Contents, Buildings, Tools, etc...

    YES NO    Coverage Desired?
Number of Locations / Buildings

Location 1

Address Same as Mailing YES NO
Deductible
$250       $500       $1,000       $2,500      
Business Contents $
Off-Premises Property / Tools and Equipment Floater $
     Individual items valued OVER $700
DESCRIPTION
VALUE
Tenants Improvements & Betterments $
Building $
 
Computers $
Spoilage Coverage $
Glass $
Linear Square Feet
Cash on Premises $
Employee Theft
  None    $10, 000    $20,000    $50, 000    Other
Business Income/ Extra Expense
If available, should be automatically included. Review proposal for coverage and limit.
Other Property Coverages

Property Info

Must be complete, even if applicant is only a tenant
Construction      Frame      Joisted Masonry      Non-Combustible      Masonry/Non Combustible      Fire Resistive

Number of stories
Year Built
Is the Business located in a residence
Yes No
Area occupied by Insured
sq ft
Any building vacancies
Yes No
(%, units or sq ft)
Alarm System
Yes No
Central Station      Security Guard      Guard Dog
Working Fire Sprinklers
Yes No
Percentage sprinklered %
Is building more than 25 years old
Yes No
Indicate year:    Wiring      Roof      Plumbing     
Other
Any renovations planned for this location
Yes No Major Minor
Customers, or other people's property held for storage or repair
Yes No
Property and Values
Any off-premises work or exposures
Yes No
List
Any other locaton or business owned/leased/used by applicant, including any unrelated operations
Yes No
List

Building Info

Building Owned by Applicant
Yes No
Landlord is requiring Tenant to insure the Building
Yes No
Why are you requesting Building coverage
is building owned under a different name
Yes No
List Name
Total building area
sq ft
Any apartments in building
Yes No
Number of apartments
and percentage of building for apartments
Other building tenants
Yes No
How many tenants
SQ Ft and Description of each

Location 2

Address Same as Mailing YES NO
Deductible
$250       $500       $1,000       $2,500      
Business Contents $
Tools and Equipment Floater/Off-Premises Property $
     Individual items valued OVER $700
DESCRIPTION
VALUE
Tenants Improvements & Betterments $
Building $
 
Computers $
Spoilage Coverage $
Glass $
Linear Square Feet
Cash on Premises $
Employee Theft
  None    $10, 000    $20,000    $50, 000    Other
Business Income/ Extra Expense
If available, should be automatically included. Review proposal for coverage and limit.
Other Property Coverages

Property Info

Must be complete, even if applicant is only a tenant
Construction      Frame      Joisted Masonry      Non-Combustible      Masonry/Non Combustible      Fire Resistive

Number of stories
Year Built
Is the Business located in a residence
Yes No
Area occupied by Insured
sq ft
Any building vacancies
Yes No
(%, units or sq ft)
Alarm System
Yes No
Central Station      Security Guard      Guard Dog
Working Fire Sprinklers
Yes No
Percentage sprinklered %
Is building more than 25 years old
Yes No
Indicate year:    Wiring      Roof      Plumbing     
Other
Any renovations planned for this location
Yes No Major Minor
Customers, or other people's property held for storage or repair
Yes No
Property and Values
Any off-premises work or exposures
Yes No
List
Any other locaton or business owned/leased/used by applicant, including any unrelated operations
Yes No
List

Building Info

Building Owned by Applicant
Yes No
Landlord is requiring Tenant to insure the Building
Yes No
Why are you requesting Building coverage
is building owned under a different name
Yes No
List Name
Total building area
sq ft
Any apartments in building
Yes No
Number of apartments
and percentage of building for apartments %
Other building tenants
Yes No
How many tenants
SQ Ft and Description of each

Location 3

Address Same as Mailing YES NO
Deductible
$250       $500       $1,000       $2,500      
Business Contents $
Tools and Equipment Floater/Off-Premises Property $
     Individual items valued OVER $700
DESCRIPTION
VALUE
Tenants Improvements & Betterments $
Building $
 
Computers $
Spoilage Coverage $
Glass $
Linear Square Feet
Cash on Premises $
Employee Theft
  None    $10, 000    $20,000    $50, 000    Other
Business Income/ Extra Expense
If available, should be automatically included. Review proposal for coverage and limit.
Other Property Coverages

Property Info

Must be complete, even if applicant is only a tenant
Construction      Frame      Joisted Masonry      Non-Combustible      Masonry/Non Combustible      Fire Resistive

Number of stories
Year Built
Is the Business located in a residence
Yes No
Area occupied by Insured
sq ft
Any building vacancies
Yes No
(%, units or sq ft)
Alarm System
Yes No
Central Station      Security Guard      Guard Dog
Working Fire Sprinklers
Yes No
Percentage sprinklered %
Is building more than 25 years old
Yes No
Indicate year:    Wiring      Roof      Plumbing     
Other
Any renovations planned for this location
Yes No Major Minor
Customers, or other people's property held for storage or repair
Yes No
Property and Values
Any off-premises work or exposures
Yes No
List
Any other locaton or business owned/leased/used by applicant, including any unrelated operations
Yes No
List

Building Info

Building Owned by Applicant
Yes No
Landlord is requiring Tenant to insure the Building
Yes No
Why are you requesting Building coverage
is building owned under a different name
Yes No
List Name
Total building area
sq ft
Any apartments in building
Yes No
Number of apartments
and percentage of building for apartments %
Other building tenants
Yes No
How many tenants
SQ Ft and Description of each

Location 4

Address Same as Mailing YES NO
Deductible
$250       $500       $1,000       $2,500      
Business Contents $
Tools and Equipment Floater/Off-Premises Property $
     Individual items valued OVER $700
DESCRIPTION
VALUE
Tenants Improvements & Betterments $
Building $
 
Computers $
Spoilage Coverage $
Glass $
Linear Square Feet
Cash on Premises $
Employee Theft
  None    $10, 000    $20,000    $50, 000    Other
Business Income/ Extra Expense
If available, should be automatically included. Review proposal for coverage and limit.
Other Property Coverages

Property Info

Must be complete, even if applicant is only a tenant
Construction      Frame      Joisted Masonry      Non-Combustible      Masonry/Non Combustible      Fire Resistive

Number of stories
Year Built
Is the Business located in a residence
Yes No
Area occupied by Insured
sq ft
Any building vacancies
Yes No
(%, units or sq ft)
Alarm System
Yes No
Central Station      Security Guard      Guard Dog
Working Fire Sprinklers
Yes No
Percentage sprinklered %
Is building more than 25 years old
Yes No
Indicate year:    Wiring      Roof      Plumbing     
Other
Any renovations planned for this location
Yes No Major Minor
Customers, or other people's property held for storage or repair
Yes No
Property and Values
Any off-premises work or exposures
Yes No
List
Any other locaton or business owned/leased/used by applicant, including any unrelated operations
Yes No
List

Building Info

Building Owned by Applicant
Yes No
Landlord is requiring Tenant to insure the Building
Yes No
Why are you requesting Building coverage
is building owned under a different name
Yes No
List Name
Total building area
sq ft
Any apartments in building
Yes No
Number of apartments
and percentage of building for apartments %
Other building tenants
Yes No
How many tenants
SQ Ft and Description of each

Workers Compensation Insurance

Fed Tax ID# Unemployment Registration #  
Total # of males Total # of females  
Entity has prior Workers Comp insurance Yes No If yes, 1 yr 2 yrs 3 yrs  
  List different employee job functions
   Annual payroll allocation
$		    
  $    
  $    
  $    
  $    
Do we have a copy of current policy Yes No If Yes, submit with application  
Does the owner want to be included                 Yes No

Auto Repair/Auto Body Shop Operations

Maximum value per customers' car $
Maximum total value of all customers' car on premises $

Completion of this section is required in order to include Garage Liability and Garagekeepers Legal Liability Coverage

24 hour operation? Yes No    
Do we directly perform Towing & Roadside assistance? Yes No    
Gasoline sales? Yes No    
More than 25% of receipts from Tire Sales? Yes No    
More than 25% of receipts from Convenience Store sales? Yes No    
Boat work? Yes No    
Own dealer plates? Yes No    
Emergency vehicle repair? Yes No    
Sell/rent/lease/loan vehicles, trailers, or tools to others? Yes No    
Perform tire retreading? Yes No    
Install trailer hitches? Yes No    
Work on race cars ? Yes No    
Sponsor racing teams? Yes No    
Self service bay rentals offered ? Yes No    
Auto wreckage operations ? Yes No    
Painting?
 Yes No
if yes, % of receipts: %  
Is painting performed in NFPA-33 approved spray booths? Yes No    
Automobile restoration or customization?
 Yes No
Explain :  
Does the prospect undertake parking/garaging operations? Yes No    
Guard dog on premises? Yes No    
Customers allowed in the shop area at any time ? Yes No    
Work performed on any vehicles over 20,000 pounds gross vehicle weight ? Yes No    
Is there at leas 1 ASE mechanic are on duty at all times? Yes No    

Church Operations

Any hospitals, homes for the aged, infirmaries, orphanages,
rehab services, sanitariums, convalescent homes, asylums, or
newspaper/web publishing (other than church bulletins)
associated with the church?


Yes No 		   
Day care operations, other than used during religious service? Yes No    
Cemetery at the premises? Yes No  
Cooking on the premises? Yes No
  If yes, grills ? Yes No
  If yes, fryer ? Yes No
Thrift-shop operation in the church? Yes No    
Premises rented out to any other functions? Yes No    
Gym on premises? Yes No    
Residence on premises? Yes No    
Playground on premises? Yes No
 
Homeless shelter on premises? Yes No  
School (k-12) on premises? Yes No


  If yes, lease or own buses or vans ? Yes No
If yes, conduct/sponsor interscholastic sports ? Yes No
If yes, conduct/sponsor travel or overnight trips ? Yes No
Own or operate camps? Yes No    
For any child or youth activity, are 2 adults always present? Yes No    
Do they sponsor any outside functions? Yes No    
  If yes, provide details regarding annual events ?    
Is the building considered a historical landmark Yes No    
How many members?    

Consultant Operations

What specifically are they paid to do?

What is the prospects finished product? Is it advice only?

Does the prospect target a specific industry?
Yes No
If yes, what industy?
Does the prospect have a brochure or website listing services provided?
Yes No
If yes, please remit?

Computer Consultant/Tech/Web

Consulting work? Yes No If yes, describe:  
    If yes, advice only?: Yes No
Website Design? Yes No  
Website Hosting? Yes No    
Website data hosting? Yes No    
Hardware Installation & Repair? Yes No    
Software Installation & Support? Yes No    
Software development? Yes No    
Programming? Yes No If yes, describe:
Any specific industries targeted? Yes No If yes, describe:  
Hardware manufacturing? Yes No    

Deli/Convenience Store Operations

24 hour operation? Yes No    
Gas station on the premises? Yes No  
Guard dog on premises? Yes No  
Delivery Services? Yes No If yes, By bike By Foot By vehicle Catering delivery
     
Table Seating? Yes No If yes, maximum seating capacity:
Table Service? Yes No  
     
Cooking on the premises? Yes No If yes, Grills Fryer
       
Hood/Duct System? Yes No Cleaning Contract ? Yes No How often cleaned
Ansul System? Yes No Cleaning Contract ? Yes No How often cleaned

Seasonal Tent / Lot Operations

Christmas Trees Flowers Pumpkin Patch
Describe Other Operations

Restaurant Operations

Experience in restaurant industry Years    
Years in business at this location Years    
Is owner active in the management of the restaurant on a daily basis? Yes No    
Seasonal Operation? Yes No If yes, describe:  
Dance Floor? Yes No    
Boat Dock? Yes No    
Lodging? Yes No    
Table Top Cooking? Yes No    
Seating? Yes No If yes, seating capacity:
 
seating area: square feet
Table top cooking: Yes No
       
Table Service? Yes No If yes, how many tables  
Bar? Yes No If yes, bar capacity
 
If yes, are servers 'TIPS' trained Yes No
       
Delivery Services? Yes No If yes, By Bike By Foot By Vehicle  
  If yes, Catering Delivery Yes No If yes, percentage receipts form catering %    
       
Entertainment? Yes No If yes, describe (piano, band, DJ)  
    How many nights a week  
       
Are there any pool tables? Yes No How many pool tables  
           
Other entertainment devices?
(i.e., dartboards, video games)		 Yes No If yes, list
       
Hours of operation    
Percentage of recipts from alcohol %    
What time is serving stopped? Food Alcohol
Member of state restaurant assoc ? Yes No    
Hood/Duct System? Yes No Cleaning Contract Yes No How often cleaned
Ansul System? Yes No Cleaning Contract Yes No How often cleaned

Wholesaler Operations

Import any 'Product'
Yes No
Percentage of 'Product' imported
%
Describe what is imported
List countried imported from

Vendor - Fair/Show/Mall/Flea Mkt

Travel to multiple locations throughout the year
Yes No
Number of events per year
Indoors Outdoors
Do you sell any of the following products:
Yes No Unknown
Collectables and memorabilia (old), Drugs, Prepackaged & Non-prescription, Hearing Aids Hobby or craft, Optical Goods presription, Toys, any used or refurbished products, or any products manufactured by applicant or sold under applicant name or label(not including prepared food)

Special Events Coverage

Applicant is a:
Concessions/Vendors/Exhibitors
Event Holder
If 'Event Holder', will there be any Concessions/Vendors/Exhibitors Present
YesNo
If yes, will applicant require that they all name the applicant as an additional insured on a $1M CGL policy
YesNo
Is the mailing address the same as applicants address
Yes No
    Mailing address
Applicants home phone
Applicants business phone
Applicants mobile phone

Optional Coverages Requested


Terrorism Coverage
Yes No
Collapse of Temporary Structure Liability
Yes No
Contractual Liability Coverage
Yes No
Hired & Non-Owned Auto Liability Coverage
Yes No
Waiver of Subrogation Coverage
Yes No

Event Information


Describe Event
Will there be music played at the event
Yes No
IPOD/CD
Type of music
Live Music
Type of music
DJ
Type of music
Number of Additional Insured
Maximum Daily Attendance
Total Attendance
Audience Age Group From - To
Will alcohol be served or be available for consumption at the event
Yes No
Will the applicant recieve any proceeds from the sale of alcohol
Yes No
Is a donation expected or an admission charge required at the event
Yes No

Events Dates & Times

Start date & Stop Date
Start Stop
Start time & Stop time
Start Stop
Total number of days event will be open

Event Security

Will there be security at this event
Yes No
Provided/Contracted by:
Venue Applicant?
If provided by applicant:
Name of security company
Security provider has liability insurance
Yes No
Security provider has named applicant as an additional insured
Yes No
Uniform Guards
Peer group ushers
Off duty police
Private armed security
Is a celebrity of high profile person attending this event
Yes No

Facility/Venue Information

Name of Facility/Venue
Street Address, City, State, Zip code
Is public access limited by fences, ropes, barricades or guard rails
Yes No
Will the event be held on premises owned, managed, or operated by applicant
Yes No
Is the event facility/venue requiring that they be named on this liability policy as an additional insured
Yes No
Is the mailing address for the venue the same
Yes No
    Venue mailing address
Any additional insured wording

Commercial Automobile

Insured's Name*
 EIN
 SS#
 DOB
Home Address
 *Financial Responsibility will be ordered on all all risks. For a corporation or partnership, use the name of the
President, CEO or partner responsible for the daily operations of the business.
Prior Insurance Carrier
 BI Limits
 Inception / Effective Date Cancel / Expiration Date
Prior Auto Policy Number Does Insured Have a GL or BOP Policy Yes No  
NOTE In some states, we charge $25 for each Additional Insured and / or Waiver or Subrogation.

Vehicle Information

 Vehicle #1 Vehicle #2 Vehicle #3
Year / Make / Model
Vehicle Type
Vehicle Identification Number (VIN)
Passenger Capacity
Numbers of Axles
Gross Vehicle Weight (if No VIN)
Trailer Hitch Yes No Yes No Yes No
Use of Vehicle / Goods Hauled
Sites Per Day
Any Personal Use Yes No Yes No Yes No
Garaging Zip Code
Total Stated Amount
(included permanently attached equipment)
Radius of Operation (Maximum radius for Tractor-Trailers except Non-truck or PD only risks is 500

Driver Information

 Drivers #1 Drivers #2 Drivers #3
Name

Marital Status Married Single Married Single Married Single
DOB
Date CDL Issued
Driver License Number
State Issued
Filing Required (list type)

Coverage's - Limits / Deductibles

(May vary by state)		 Vehicle #1 Vehicle #2 Vehicle #3
BI / PD
UM / UIM
PIP
Medical Payments
Comprehensive or F&T w/CAC
Collision
On-Hook Towing
Non-Trucking / Bobtail / Contingent Liability
Non-Owned (include # of Employees)
Hired Auto (include annual cost)
Garagekeeper's Legal Liability
Trailer Interchange (includes # of trailers)

Policy & Claims History

Have any of your insurance Policies been cancelled or non-renewed in the past three years     Yes No
Explain

 
Prior
Coverage
 
Most Recent
Ins Carrier
Do we have a
Copy of the
Current Policy
 
Coverage
 Lapses
 
Number of
Policy Years
 
Expiring
Premium
 
Expiration
   Date
General Liability
Yes No
Yes No
Yes No
Property
Yes No
Yes No
Yes No
Workers Compensation
Yes No
Yes No
Yes No
Commercial Automobile
Yes No
Yes No
Yes No
Umbrella
Yes No
Yes No
Yes No
Employment Practices
Yes No
Yes No
Yes No
Directors and Officers
Yes No
Yes No
Yes No
Professional Liability
Yes No
Yes No
Yes No
N.Y. State DBL
Yes No

Any claims in the last four years
Yes No
Any preventative measures taken to prevent similar loss
Claim Descriptions
Policy Type
Claim Date
Claim Amount
Open Claim
Yes No
Yes No
Yes No

Notes