Step 1 of 8 12% Type of Insurance Requested(Required) General Liability Property Workers Compensation Commercial Auto Professional Liability Commercial Umbrella Directors & Officers Inland Marine Builders Risk Primary Contact InformationPrimary Contact Name(Required) First Last Email(Required) Phone(Required)Address(Required) Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Business InformationName of Business(Required) Name Year Business Started(Required) MM slash DD slash YYYY Type of Entity(Required) Estimated Annual Revenue(Required)Additional Business InformationNumber of Active LLC OwnersFEINListName% Ownership Add RemoveAny prior insurance for this business?(Required)YesNoDoes the business have employees?(Required)YesNoAny Prior Insurance for BusinessName of Prior Insurance Company Name Type of Prior Insurance Ex. General Liability, Commercial Auto, etc.Reason for Shopping Any Insurance Claims in the past 5 yearsYesNoEmployeesHow many Full Time Employees?How Many Part-Time Employees?Estimated Annual PayrollDetailed Business Description(Required)Please describe what the business does and any incidental operations. Builders RiskProperty Address Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Is this Builders Risk for new construction?YesNoTotal Square FootageEstimated Occupancy Date MM slash DD slash YYYY Original Year BuiltBuilders Risk Information – RenovationCost of ConstructionName of General Contractor First Umbrella LimitsUmbrella Limits Requested1,000,0002,000,0003,000,0004,000,0005,000,000+Please indicate any other states or countries you operate in: Is an umbrella required by a contract or agreement?YesNoPlease attach a draft or sample of contract if availble:Max. file size: 100 MB. Directors & OfficersHow many active Directors & Officers are there in entity? Professional LiabilityList all the professional services you provide:If applicable, list what % these services make up the business. Property CoverageType of Property Coverage Requested Building Coverage Contents Coverage How much contents coverage is needed?Please list a $ amount.PropertyProperty Location(s)List all addresses you wish to seek coverage onIs this property a new purchase?YesNoNew Purchase QuestionsEstimated Closing Date MM slash DD slash YYYY Name of Lender (If Applicable) Name OccupancyType of Occupancy 1-4 Unit Dwelling 5+ Unit Apartment Building Retail Office Manufacuring Restaurant Other Describe Occupancy Was the property constructed before 2003?YesNoWhich of the following been updated in the past 20 years? Roof Plumbing Heating Electrical Vehicle/DriverVehicle Information Year, Make, Model and VIN of VehicleDriver Information(Required) Name, Date of Birth, & Drivers License Number Subcontractors QuestionsDoes the business hire subcontractorsYesNoAnnual Cost of SubcontractorsType of Work Performed by Subs Additional CommentsCoverage limits requested, special requests, anything you’d like us to know.Consent(Required) I agree to the Lotfey Dennett Insurance Brokers privacy policy and consent to being contacted via phone call, text message and email about my request.
