POLICY RECOMMENDATIONS(Please check any you are interested in)
Accident Medical
Inland Marine
Worker's Compensation
Commercial Auto
EPLI
Hired & Non-Owned Auto
Umbrella
Abuse/Molestation
Cyber Liability
Section 1: Submission Requirements
Please Note: We must receive the documents below before a quote is issued. Thank you for your cooperation.
1) Resume (New Business Only)
2) Lease Agreement
3) Daily Safety Checklist
4) Diagram of premises
5) Safety Rules
6) Waiver
7) Loss runs for last 5 yrs.
8) Business & Financial Plan (New Business Only)
9) Evacuation Diagram & Procedures
Section 1: COMPANY INFORMATION
How did you hear about us?
Choose One
Bing
Customer Referral
Google
Manufacturer
Other
Postcard
Social Media
Trade Show
Yahoo
Are you an ERS or Inflatable Office customer?
Yes
No
Applicant Name:
Contact Name:
FEIN/SS#:
DOB:
Phone Number:
Mobile Number:
Website:
Email:
Address
Mailing Address:
City:
State:
Zip code:
Location Address:
City:
State:
Zip code:
Proposed Effective Date - From:
to
Years in business:
Experience of Owners/Principals:
If this is a new operation please provide details on owners’/principal’ prior experience (attach resume)
Do you ever process payment cards?
Yes
No
Estimated annual number of payment card transactions:
Create Password (this will allow you to access you application at a later time) :
Submit
Please make sure that you have completed everything to the best of your knowledge before going to the next page.