Business Owners-Worker’s Compensation Policy

Purpose of Application
New PolicyLocation MoveAdd Location
Desired Effective Date

Year Business was established or acquired from previous owner

Type of Business Entity
Individual

Corp
Other

Legal Business Name

If Other. D/B/A Name

Federal Tax ID

Expected Annual Gross Sales

Physical Primary Location

Year Building Built

Owner or Tenant?
OwnerTennant

Personal Property Coverage*
(Amount needed to replace contents)

Personal Property Deductible Option
$500 (Most Common)$1000
General Liability Limit
1,000,000/2,000,000Other

Full Time Employees

Part Time Employees

Type of Outside Construction
BrickStuccoOther

Building Sprinklered
Yes

No
Fire Alarm
NoneLocalCentral
Buglar Alarm Type
NoneLocalCentral
Number of Stories

Basement
YesNo
Year Updates Were Completed (if building over 25 years old)

Full time Employees

Part time Employees

Umbrella Coverage? YesNo
Limit 1m2m
Include Doctor YesNo

Payroll Amount for Massage Therapists

Annual Expected Payroll

Claims History YesNo

Has Prior Coverage ever been cancelled? YesNo

Business/Entity Name

Physical Primary Location

TAX ID Number

Purpose of Application
New PolicyLocation MoveAdd Location
Desired Effective Date

Year Business was established or acquired from previous owner

Type of Business Entity
Individual

Corp
Other

Legal Business Name

If Other. D/B/A Name

Federal Tax ID

Expected Annual Gross Sales

Physical Primary Location

Year Building Built

Owner or Tenant?
OwnerTennant

Personal Property Coverage*
(Amount needed to replace contents)

Personal Property Deductible Option
$500 (Most Common)$1000
General Liability Limit
1,000,000/2,000,000Other

Full Time Employees

Part Time Employees

Type of Outside Construction
BrickStuccoOther

Building Sprinklered
Yes

No
Fire Alarm
NoneLocalCentral
Buglar Alarm Type
NoneLocalCentral
Number of Stories

Basement
YesNo
Year Updates Were Completed (if building over 25 years old)

Full time Employees

Part time Employees

Umbrella Coverage? YesNo
Limit 1m2m
Include Doctor YesNo

Payroll Amount for Massage Therapists

Annual Expected Payroll

Claims History YesNo

Has Prior Coverage ever been cancelled? YesNo

Business/Entity Name

Physical Primary Location

TAX ID Number