Avanti Business and Insurance Services

Name

Email

Phone

Message

Please complete the information below. IMPORTANT: This form is not an insurance policy – it asks for general information necessary to prepare a quotation. Note that many carriers require a complete signed carrier application specific to their product offerings.

GENERAL INFORMATION

Applicant Name:

Business Name:

Mailing Address:

Phone:

Email:

Legal Entity (Select one):

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Corporation
LLC
Partnership
Individual
Not for Profit
Other

If "Other," Please Specify:

Date Business Established:

FEIN:

SIC Code:

Years in Operation:

Description of Operations (Min. 10 words):

Number of Full Time Employees:

Number of Part Time Employees:

Number of Volunteers:

Gross Annual Payroll:

Gross Annual Revenue:

Insurance Coverage Requested (Check all that apply):

Business Owners Policy (BOP)
General Liability
Professional Liability
Commercial Auto
Workers' Comp.
Other

Current Insurance Carrier (If no insurance, enter "NONE"):

Current Policy Expiration Date:

Current Limits:

Desired Effective Date for New Policy:

Desired Limits:

Desired Deductible:

PROPERTY DETAILS

Are you requesting Property Coverage?

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Yes
No

If "No," list the current carrier - If no current insurance, enter "NONE":

Do employees handle cash?

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Yes
No

Building Ownership (Choose one):

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Owned
Lease
Triple Net Lease

Please provide the following building information:

Insured Square Feet:

Occupied Square Feet:

Unoccupied Square Feet:

Total Square Feet:

Describe the Other Occupants:

Construction Type:

Number of Stories:

% Sprinklered:

Is the building within city limits?

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Yes
No

Year Built:

Building Security Information:

Fire Alarm:

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None
Local
Central

Burglar Alarm:

--
None
Local
Central

Smoke Detectors:

--
None
Battery
Hardwired

Property Value Information:

Building:

Personal Property:

GENERAL LIABILITY

Are you requesting General Liability Coverage?

--
Yes
No

If "No," list the current carrier - If no current insurance, enter "NONE":

Desired Amount of General Liability Coverage:

Are any autos used exclusively for business use?

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Yes
No

Do any employees use a personal auto for business use?

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Yes
No

Are any web based services offered?

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Yes
No

Are credit card payments accepted?

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Yes
No

Is there a program in place to identify and prevent identity theft?

--
Yes
No

PROFESSIONAL LIABILITY

Are you requesting Professional Liability Coverage?

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Yes
No

If "No," list the current carrier - If no current insurance, enter "NONE":

Desired Amount of Professional Liability Coverage:

Describe Professional Services Offered (Min. 10 words):

How many Full Time ICs or Sub Contractors do you employ?

How many Part Time ICs or Sub Contractors Do you employ?

What was the percentage of your firm's gross Fees paid to ICs or Sub Contractors last year?

Do you provide Professional Liability to your ICs and Sub Contractors?

--
Yes
No

ALLIED MEDICAL AND MEDICAL PROFESSIONAL LIABILITY

Are you requesting Allied Medical Professional Liability Coverage?

If "No," list the current carrier - If no current insurance, enter "NONE":

Desired amount of Medical Professional Liability Coverage:

Do you employ physicians or surgeons?

--
Yes
No

Is there a Medical Director

--
Yes
No

If "Yes," does the Medical Director have their own insurance?

--
Yes
No

Do you bill for Medicare/Medicaid?

--
Yes
No

WORKERS' COMPENSATION

Are you requesting Workers' Compensation Coverage?

If "No," list the current carrier - If no current insurance, enter "NONE":

Number of employees:

Are medical benefits Offered?

--
Yes
No

Do you offer paid vacation?

--
Yes
No

Does your business have a formal safety plan?

--
Yes
No

In the space provided below, please provide a description of employee positions by duty, the number of Full Time and Part Time employees for each position, and the estimated payroll for each position:

Please list owners/employees to be excluded in a Workers' Comp evaluation by name, title and estimated payroll:

ADDITIONAL COVERAGE INTERESTS

Select all that apply:

Bonds
Buy/Sell Agreement
Commercial Umbrella
Crime/Employee Dishonesty
Cyber Liability
Directors and Officers Liability
Employment Practices Liability
Medicare/Medicaid Billing E&O
Regulatory Shut Down
Other