Baldwin-Cox Agency : Construction Bonds, Commercial Insurance, Employee Benefits, Personal Lines

Business Insurance Form

Instructions: Complete the General Information section and only the sections for the line of insurance that you want quoted. If you have any questions, please call 972-644-8035.

General Information
Company Name:		Date:
Company Contact:		Title:
Company Address	Street Address

Phone:		E-mail Address:
# of Employees:		# Years in Business:
Description of Operations:		Federal Tax ID #:
Complete “Named Insured” List:		Owner(s) Name & Percentage:
		Owner(s) Name & Percentage:
		Owner(s) Name & Percentage:
Gross Receipts (Current):	Prior:	2 Years Prior:	3 Years Prior:
Lines of Business to be Quoted:	GL WC Auto Property Equipment Umbrella Other (list below)

Commercial General Liability
Projected Gross Annual Receipts:		($)
Projected Annual Payroll/Subcontract Costs:		($)
Coverage Limits:	Non Owned Hired Automobile Liability:($)
Is Liquor Liability Needed?: Yes No
Please List Relevant Exposures or Other Coverages Needed:

* May require additional supplemental application. * Provide last 5 years of cu rrently valued loss runs.
Excess Liability / Umbrella:	Limits Needed:	Other:

Workers Compensation
# of Years in Business:		Annual Renewal Date:
Current W.C. Carrier:		Current Experience Modification Factor (provide copy):
Payroll Information
Classification	# of Employees	Projected Annual Payroll




Additional Comments:
Please Provide First Page & Table of Contents of Safety Manual AND Last 5 Years Currently Valued Loss Runs

Property
Age of Building / Year Built:		Type of Building Construction:
Number of Stories:		Square Feet:
If Building is Over 25 Years Old, Please Answer the Following:
Year Electricity was Updated:		Is It on Circuit Breakers:	Yes No
Year Plumbing was Updated:		Plumbing Material:
Year Building was last Re-roofed		Type of Roofing Material:
Type of Heating System in Building:
Protective Devices
Burglar Alarm: Yes No		Security:
Name of Alarm Company:
Is Building Sprinklered:	Yes No	Smoke Detectors:	Yes No
Coverage Limits
Building:	$	Contents (equipment, inventory, supplies, etc.):	$
Deductible:		Business Income/(Loss of Income):	$
Money & Securities:	$	Glass or Signs:	$
If Glass Coverage is Needed, Please Provide Dimensions:
Please List Other Coverages:		Mortgage/Loss Payee:
Name of Additional Insured:		Status:
Mailing Address:	Street Address

Equipment
Please attach the following to this form:
	Schedule of Equipment (Owned) including serial numbers and values
	Unscheduled Equipment Limit (Items Valued Under $1,000)
	Leased & Rented Equipment Limit & Annual Rental/Lease Cost
	Builders Risk or Installation Limit

Automobile
Liability Limit:		Uninsured Motorist Bodily Injury:
Uninsured Property Damage:	Yes No	Medical:
Hired Auto:	Yes No	Comprehensive Deductible:	Yes* No
*If YES, Select One:
Non-Owned Auto:	Yes No	Collision Deductible:	Yes* No
*If YES, Select One:
Please Provide… › Vehicle Schedule* › Driver Schedule (Name, DL# and Birthdate) › Loss Runs For Last 3 Years

Optional Coverages
Select Optional coverages that you are interested in:
	Employees Practice Liability
	Garage Keepers Coverage
	Contractors Equipment
	Builder’s Risk