Commercial Insurance Application

Company Information
Company Name Required
Location # Optional
First Name Required Input Required
Last Name Required Input Required
Street Required Input Required
City Required Input Required
State Required Input Required	select TX
ZIP / Postal Code Required Input Required Please enter a valid Postal code.
Primary Phone Number Required Input Required Please enter a valid phone number
E-Mail Address Required You must provide an e-mail address. A valid e-mail address is required.
Coverage(s) Requested Optional	Business Auto Commercial General Liability Electronic Data Protection Equipment Floater Property Builder's Risk Umbrella Other
SIC Code (if known) Optional
City Limits Required City Limits is required.	select Please Select In the City Limits Out of the City Limits
Number of Full Time Employees Required Number of Full Time Employees is required.
Number of Part Time Employees Required Number of Part Time Employees is required.
Annual Revenues $ Required Annual Revenues is required.
Occupied Area Required Occupied Area is required.
Total Area in Building Required Total Area in Building is required.
Open to the Public Required Open to the Public is required.	select Please Select Yes No
Nature of Business Required Nature of Business is required.	select Please Select Apartments Condominiums Contractor Institutional Manufacturing Office Restaurant Retail Service Wholesale Other
Description of Primary Operations Required Description of Primary Operations is required.
Is the Applicant a subsidiary of another entity? Required Is the Applicant a subsidiary of another entity? is required.	select Please Select Yes No
If "Yes", Parent Company Name Required If "Yes", Parent Company Name is required.
Relationship Description Required Relationship Description is required.
Percentage Owned Required Percentage Owned is required.
Does the Applicant have any susidiaries? Required Does the Applicant have any susidiaries? is required.	select Please Select Yes No
If "Yes", Subsidiaries Company Name Required If "Yes", Subsidiaries Company Name is required.
Relationship Description Required Relationship Description is required.
Percentage Owned Required Percentage Owned is required.
Is a formal safety program in operation? Optional	Safety Manual Safety Position Monthly Meetings OSHA Other
Any exposure to flammables, explosives, chemicals? Required Any exposure to flammables, explosives, chemicals? is required.	select Please Select Yes
If "Yes", please explain. Required If "Yes", please explain is required.
Any other insurance with this company? Optional	Please Select Yes No
If "Yes", please list line of business and policy numbers Required If "Yes", please list line of business and policy numbers is required.
Any policy or coverage declined, cancelled or non-renewed during the prior three (3) years for any premises or operations? (Missouri Applicants - Do not answer this question) Required Any policy or coverage declined, cancelled or non-renewed during the prior three (3) years for any premises or operations? (Missouri Applicants - Do not answer this question) is required.	select Please Select Yes No
If "Yes", please select the appropriate boxes Optional	Non-Payment Non-Renewal Agent No Longer Represents Carrier Underwriting Other Condition Corrected (Describe):
Any past losses or claims relating to sexual abuse or molestation allegations, discrimination or negligent hiring? Required Any past losses or claims relating to sexual abuse or molestation allegations, discrimination or negligent hiring? is required.	select Please Select Yes No
If "Yes", please explain. Required If "Yes", please explain. is required.
Enter Validation Code Required

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