LG CL Auto - StakWise

Commercial Lines Auto Form

Step 1 of 3

33%

Business Details

Assigned Advisor

How did you hear about us?

Internal Referral Sources

Who Referred you?

Business Name:

Business Website:

Business Entity

FEIN / Tax-ID Number or Social Security Number

Primary Contact Name

First Last

Phone Number:

Email:

Names and % of Ownership for all Officers:

Full Name

Position

% of Ownership

Mailing Address:

Street Address City State ZIP Code

Is Physical Address Same As Mailing Address?

Yes

No

Location Address:

Street Address City State ZIP Code

Years of Experience

Requested Effective Date:

MM slash DD slash YYYY

Year Business Started:

Coverage(s) Needed

Business Auto

Building/Property

Cyber Liability

General Liability

Workers Comp

Are You A Contractor?

Yes

No

Do you use multi-factor authentication?

Yes

No

Do you currently carry cyber liability?

Yes

No

Current Cyber Carrier

Number of Full-Time Employees:

Number of Part-Time Employees:

Workers Comp Employee List

Employee Name

Position

FT/PT

Annual Salary

Owners Included With Workers Comp?

Yes

No

Estimated Annual Payroll:

Estimated Gross Annual Revenue/Sales:

Amount of Liability Coverage

Amount of Business Contents/Property Coverage

Please provide a short description of business operations:

Additional Contractor Details

Contractors License #

% of work Subcontracted out

% of Residential Work

% of Commercial Work

% of Remodel/Install work

% of New Construction Work

% of Service/Maintenance Work

Do you perform Government/Municipality Work?

Tools/Equipment coverage needed?

Any items valued over $5,000

List

Item Description

Value

Business Auto Information

How many vehicles are owned by the business?

How many trailers are owned by the business?

How many drivers work for the business?

Current Carrier:

Current Payment Plan:

Vehicle List

Please upload a spreadsheet with your company owned vehicles

Drop files here or

Max. file size: 100 MB, Max. files: 3.

Include VIN, Year, Make, Model

Vehicle #1

Vehicle #1 VIN

# of jobs per day

Coverage Needed

Liability Only

Full Coverage

Value of Vehicle

Deductible

Hitch

No

Yes in Bed/Bumper

Flatbed?

Yes

No

Gross Weight

# of Axels

Vehicle #2

Vehicle #2 VIN

# of jobs per day

Coverage Needed

Liability Only

Full Coverage

Value of Vehicle

Deductible

Hitch

No

Yes in Bed/Bumper

Flatbed?

Yes

No

Gross Weight

# of Axels

Vehicle #3

Vehicle #3 VIN

# of jobs per day

Coverage Needed

Liability Only

Full Coverage

Value of Vehicle

Deductible

Hitch

No

Yes in Bed/Bumper

Flatbed?

Yes

No

Gross Weight

# of Axels

Vehicle #4

Vehicle #4 VIN

# of jobs per day

Coverage Needed

Liability Only

Full Coverage

Value of Vehicle

Deductible

Hitch

No

Yes in Bed/Bumper

Flatbed?

Yes

No

Gross Weight

# of Axels

Vehicle #5

Vehicle #5 VIN

# of jobs per day

Coverage Needed

Liability Only

Full Coverage

Value of Vehicle

Deductible

Hitch

No

Yes in Bed/Bumper

Flatbed?

Yes

No

Gross Weight

# of Axels

Trailer #1

Trailer Value

Length

Is trailer enclosed?

Yes

No

Serial #

Trailer #2

Trailer Value

Length

Is trailer enclosed?

Yes

No

Serial #

Trailer #3

Trailer Value

Length

Is trailer enclosed?

Yes

No

Serial #

Trailer #4

Trailer Value

Length

Is trailer enclosed?

Yes

No

Serial #

Driver List

Please upload a list of drivers that work for your company.

Drop files here or

Max. file size: 100 MB, Max. files: 3.

Include name, date of birth and driver's license number

Driver #1

Name

First Last

DL#

SSN

Date of Birth

MM slash DD slash YYYY

Accidents/Violations/License Suspensions in last 3 years?

Yes

No

Driver #2

Name

First Last

DL#

SSN

Date of Birth

MM slash DD slash YYYY

Accidents/Violations/License Suspensions in last 3 years?

Yes

No

Driver #3

Name

First Last

DL#

SSN

Date of Birth

MM slash DD slash YYYY

Accidents/Violations/License Suspensions in last 3 years?

Yes

No

Driver #4

Name

First Last

DL#

SSN

Date of Birth

MM slash DD slash YYYY

Accidents/Violations/License Suspensions in last 3 years?

Yes

No

Driver #5

Name

First Last

DL#

SSN

Date of Birth

MM slash DD slash YYYY

Accidents/Violations/License Suspensions in last 3 years?

Yes

No

Building/Property

Current Carrier

Interest in Building:

Owner

Tenant

% of building occupied:

% leased to others:

Building originally built:

Slab

Crawl Space

Building type:

Frame

Masonry

If frame what type of siding?

Wood

Vinyl

Stories:

1

2

3

Total Square Feet:

Roof Age:

Roof Type

Shingles

Wood Shingles

Metal

Clay Tiles

Age of Wiring:

Plumbing:

Heating:

Sprinkler System:

Yes

No

Need Sign Coverage:

Yes

No

Amount of Coverage

Is there a Premises Alarm Active?

Yes

No

Is there a Safe or Vault?

Yes

No

How often does applicant make a deposit of cash?

Value of Building:

Value of Personal Contents:

Coverage requested: