Insurance Application Questions – Commercial Lines – Multi-Policy

ALLCHOICE Agent Information
Select Your Advisor*
LINE OF BUSINESS
Indicate Line(s) Of Business You Are Requesting
Lines Of Business Requested
- Commercial General Liability
- Commercial Property
- Business Auto (Acord 127)
- Workers Compensation
- Umbrella
- Business Owners
- Commercial Inland Marine
- Crime
- Garage & Dealers
- Cyber & Privacy
- Fiduciary Liability
- Liquor Liability
- Motor Carrier
- Truckers
- Boiler & Machinery (Acord 155 BM)
INSURED INFORMATION
Applicant Name (Name of Business)
Primary Contact*
First Last
Mobile Phone*
Primary Email*
Are Mailing & Location Address Different
- No
- Yes
Mailing Address
Street Address City State ZIP Code
Location Address
Street Address City State ZIP Code
Are there additional locations?
- No
- Yes
List other locations (include full address)
Legal Entity Type
Tax | Federal ID
Number of Employees
Annual Revenue
Annual Payroll
NATURE OF BUSINESS
Type Of Business Operations
- Apartments
- Condominiums
- Contractor
- Institutional
- Manufacturing
- Office
- Restaurant
- Retail
- Service
- Wholesale
Number of years in business
Description Of Operations
Installation, Service Or Repair Work (as a % of Total Revenue)
OFF Premises – Installation, Service Or Repair Work (as a % of Total Revenue)
COMMERCIAL GENERAL UNDERWRITING
1A. Is the Applicant a Subsidiary of another entity?
- No
- Yes
Explain (Give Name Of Entity)
1B. Does the Applicant have any subsidiaries?
- No
- Yes
Explain
2. Is a formal safety program in operation?
- No
- Yes
Explain
3. Any Exposure to flammables, explosives, chemicals, or Radioactive/nuclear materials?
- No
- Yes
Explain
5. Any policy or coverage declined, cancelled or non-renewed during the prior 3 years?
- No
- Yes
Explain
6. Any past losses or claims relating to sexual abuse or molestation allegations, discrimination or negligent hiring?
- No
- Yes
Explain
7. During the last 5 years, has any applicant been indicted for, or convicted of any degree of the crime of fraud, bribery, arson or any other arson related crime?
- No
- Yes
8. Any uncorrected fire and/or safety code violations?
- No
- Yes
Explain
9. Has Applicant had a foreclosure, repossession, bankruptcy or filed for bankruptcy in the past 5 years?
- No
- Yes
Explain
10. Has application had a judgement or lien during the last five (5) years?
- No
- Yes
Explain
11. Has the business been placed in a trust?
- No
- Yes
Name Of Trust
12. Any foreign operations, foreign products distributed in USA, or US products sold / distributed in foreign countries?
- No
- Yes
Explain
13. Does applicant have other business ventures for which coverage is NOT requested?
- No
- Yes
Explain
14. Does Applicant hire others to operate drones?
- No
- Yes
Explain (Describe Use)
15. Does applicant hire others to operate drones?
- No
- Yes
Explain (Describe Use)
PRIOR CARRIER INFORMATION
Prior Coverage Type(s)*
- No Current Or Prior Insurance (new venture)
- General Liability Insurance
- Business Automobile Insurance
- Commercial Property Insurance
- Workers Compensation Insurance
- Commercial Umbrella Insurance
**Check ALL Current & Prior Coverage Types You Have/Had**
General Liability Prior Coverage Information
Include The Following For The Previous Three (3) Policy Periods: 1. Insurance Carrier 2. Policy Number (If Available) 3. Premium 4. Expiration Date
Business Automobile Prior Coverage Information
Include The Following For The Previous Three (3) Policy Periods: 1. Insurance Carrier 2. Policy Number (If Available) 3. Premium 4. Expiration Date
Commercial Property Prior Coverage Information
Include The Following For The Previous Three (3) Policy Periods: 1. Insurance Carrier 2. Policy Number (If Available) 3. Premium 4. Expiration Date
Workers Compensation Prior Coverage Information
Include The Following For The Previous Three (3) Policy Periods: 1. Insurance Carrier 2. Policy Number (If Available) 3. Premium 4. Expiration Date
Commercial Umbrella Prior Coverage Information
Include The Following For The Previous Three (3) Policy Periods: 1. Insurance Carrier 2. Policy Number (If Available) 3. Premium 4. Expiration Date
PRIOR CLAIMS
Have there been any Claims in the past 5 years?
- No
- Yes
Explain
1. Include Date Of Occurrence 2. Description Of Claim 3. Amount Paid 4. Amount Reserved 5. Subrogated (Yes or No) 6. Is The Claim Open Or Closed)
BOILER & MACHINERY (ACORD 155 BM)
AGE OF OLDEST MACHINERY & EQUIPMENT
1. ARE EQUIPMENT MAINTENANCE, OVERHAUL, MONITORING, DISASSEMBLY AND REPAIR CONDUCTED ACCORDING TO MANUFACTURERS' INSTRUCTIONS?
- Yes
- No
Explain
2. IS ALL EQUIPMENT ACCESSIBLE WITH RESPECT TO REPAIR OR REPLACEMENT?
- Yes
- No
EXPLAIN
3. ARE ALL EQUIPMENT INSTRUMENTATION AND CONTROLS IN ACCORDANCE WITH MANUFACTURERS' SPECIFICATIONS?
- Yes
- No
EXPLAIN
4. ARE CHLOROFLUOROCARBON (CFC) REFRIGERANTS USED IN THE MACHINERY TO COOL ANY PART OF THE PREMISES OR PROCESS?
- Yes
- No
EXPLAIN
5. IS ALL MACHINERY AND EQUIPMENT IN GOOD CONDITION?
- Yes
- No
EXPLAIN
BUSINESS AUTO SECTION (ACORD 127)
1. WITH THE EXCEPTION OF ANY ENCUMBRANCES, ARE ANY VEHICLES FOR WHICH INSURANCE IS REQUESTED NOT SOLELY OWNED BY AND REGISTERED TO THE APPLICANT?
- No
- Yes
EXPLAIN
1. Identify Which Vehicle Is Owned By Someone Else, and Name The Owner Of That Vehicle
2. DO OVER 50% OF THE EMPLOYEES USE THEIR AUTOS IN THE BUSINESS?
- No
- Yes
3. IS THERE A VEHICLE MAINTENANCE PROGRAM IN OPERATION?
- No
- Yes
EXPLAIN
1. Give Details Of Maintenance Program
4. ARE ANY VEHICLES LEASED TO OTHERS?
- No
- Yes
EXPLAIN
5. ANY CAR/VEHICLE MODIFIED OR HAVE SPECIAL EQUIPEMENT?
- No
- Yes
EXPLAIN
1. List vehicle | description of modifications | value of modifications/equipment
6. ARE ICC, PUC, OR OTHER FILINGS REQUIRED?
- No
- Yes
EXPLAIN
1. List Any Filings Needed
7. DO OPERATIONS INVOLVE TRANSPORTING HAZARDOUS MATERIAL?
- No
- Yes
EXPLAIN
List All Hazardous Material Transported
8. ANY HOLD HARMLESS AGREEMENTS?
- No
- Yes
EXPLAIN
9. ANY VEHICLES USED BY FAMILY MEMBERS?
- No
- Yes
EXPLAIN
10. DOES APPLICANT OBTAIN MVR VERIFICATIONS?
- No
- Yes
EXPLAIN
11. DOES THE APPLICANT HAVE A SPECIFIC DRIVER RECRUITING METHOD?
- No
- Yes
EXPLAIN
12. ARE ANY DRIVERS NOT COVERED BY WORKERS COMPENSATION?
- No
- Yes
EXPLAIN
13. ANY VEHICLES OWNED BY NOT SCHEDULED ON THIS APPLICATION?
- No
- Yes
EXPLAIN
14. ANY DRIVERS WITH CONVICTIONS FOR MOVING TRAFFIC VIOLATIONS?
- No
- Yes
EXPLAIN
15. HAS AGENT INSPECTED VEHICLES?
- No
- Yes
*Check “NO” Unless The Insurance Agent You Are Submitting This Application To Has Already Inspected The Vehicle(s)
16. ARE ALL VEHICLES TO BE INCLUDED IN THIS POLICY PART OF A FLEET?
- No
- Yes
17. DO YOU HAVE ELECTRONIC MONITORING DEVICES THAT RECORD AND TRANSMIT DATA IN ANY OF YOUR VEHICLES?
- No
- Yes
WHAT % OF VEHICLES ARE MONITORED (1-100%)
PLEASE INDICATE HOW YOU UTILIZE THE DEVICES (CHECK ALL THAT APPLY)
- Select All
- Monitor Driver Safety
- Navigation
- Track Fuel Consumption
- Monitor Vehicle Maintenance
- Mileage Tracking
- Location Tracking
DESCRIPTION OF GARAGE / STORAGE LOCATIONS
**include safety details (ex. fenced location, alarmed, security guard, video monitoring, etc)
MAXIMUM DOLLAR VALUE SUBJECT TO LOSS
(Approximate Value Of All Vehicles At One Location)
INDIVIDUALS INCLUDED / EXCLUDED
Number of Owners | Officers | Partners
Owner | Officer | Partner 1
First Last
Owner | Officer | Partner 1 – Date of Birth
MM slash DD slash YYYY
Owner | Officer | Partner 1 – Title
Owner | Officer | Partner 1 – Ownership %
Owner | Officer | Partner 1 – Duties
Owner | Officer | Partner 1 – Payroll | Compensation
Owner | Officer | Partner 1 – Include | Exclude From Coverage
Owner | Officer | Partner 2
First Last
Owner | Officer | Partner 2 – Date of Birth
MM slash DD slash YYYY
Owner | Officer | Partner 2 – Title
Owner | Officer | Partner 2 – Ownership %
Owner | Officer | Partner 2 – Duties
Owner | Officer | Partner 2 – Payroll | Compensation
Owner | Officer | Partner 2 – Include | Exclude From Coverage
Owner | Officer | Partner 3
First Last
Owner | Officer | Partner 3 – Date of Birth
MM slash DD slash YYYY
Owner | Officer | Partner 3 – Title
Owner | Officer | Partner 3 – Ownership %
Owner | Officer | Partner 3 – Duties
Owner | Officer | Partner 3 – Payroll | Compensation
Owner | Officer | Partner 3 – Include | Exclude From Coverage
Owner | Officer | Partner 4
First Last
Owner | Officer | Partner 4 – Date of Birth
MM slash DD slash YYYY
Owner | Officer | Partner 4 – Title
Owner | Officer | Partner 4 – Ownership %
Owner | Officer | Partner 4 – Duties
Owner | Officer | Partner 4 – Payroll | Compensation
Owner | Officer | Partner 4 – Include | Exclude From Coverage
Owner | Officer | Partner 5
First Last
Owner | Officer | Partner 5 – Date of Birth
MM slash DD slash YYYY
Owner | Officer | Partner 5 – Title
Owner | Officer | Partner 5 – Ownership %
Owner | Officer | Partner 5 – Duties
Owner | Officer | Partner 5 – Payroll | Compensation
Owner | Officer | Partner 5 – Include | Exclude From Coverage
WORKERS COMPENSATION GENERAL UNDERWRITING
Does Applicant own, operate or lease aircraft / watercraft?
- No
- Yes
Do / have past, present or discontinued operations involve(d) storing, treating, discharging, applying, disposing, or transporting or hazardous material?
- No
- Yes
Any work performed underground or above 15 feet?
- No
- Yes
Any work performed on barges, vessels, docks, bridges over water?
- No
- Yes
Is applicant engaged in any other type of business?
- No
- Yes
Are sub-contractors used?
- No
- Yes
Give % of work subcontracted (and type)
Any work sublet without Certificates of Insurance?
- No
- Yes
Is there a written safety program in operation?
- No
- Yes
Any group transportation provided?
- No
- Yes
Any employees under 16 or over 60 years or age?
- No
- Yes
Any seasonal employees?
- No
- Yes
Is there any volunteer or donated labor?
- No
- Yes
Explain
Any employees with physical handicaps?
- No
- Yes
Do employees travel out of state?
- No
- Yes
What States? How often?
Are athletic teams sponsored?
- No
- Yes
Are physicals required after offers or employment are made?
- No
- Yes
Are employee health plans provided?
- No
- Yes
Do any employees perform work for other businesses or subsidiaries?
- No
- Yes
Do you lease employees to or from other employers?
- No
- Yes
Do any employees predominately work at home?
- No
- Yes
How Many?
Any disputed and unpaid workers compensation premium due from you or any commonly managed or owned enterprises?
- No
- Yes
Please explain, including entity name(s) | carriers | policy numbers
CARRIER SPECIFIC UNDERWRITING QUESTIONS
Do any employees have any "out of state" exposure, outside of primary state?
- No
- Yes
Explain
Has the Applicant or any partner, corporate officer, member or director ever been convicted or otherwise found guilty of a crime (Excluding offenses committed while a juvenile or sealed by court order)?
- No
- Yes
Explain
Are employees exposed under U.S. Longshoremen's and Harborworkers' Act of the Federal Employee's Liability Act?
- No
- Yes
Explain

Insurance Application Questions – Commercial Lines – Multi-Policy

Insurance Application Questions – Commercial Lines – Multi-Policy

ALLCHOICE Agent Information

LINE OF BUSINESS

INSURED INFORMATION

NATURE OF BUSINESS

COMMERCIAL GENERAL UNDERWRITING

PRIOR CARRIER INFORMATION

PRIOR CLAIMS

BOILER & MACHINERY (ACORD 155 BM)

BUSINESS AUTO SECTION (ACORD 127)

INDIVIDUALS INCLUDED / EXCLUDED

WORKERS COMPENSATION GENERAL UNDERWRITING

CARRIER SPECIFIC UNDERWRITING QUESTIONS