Business Owners Policy Application

1. Your Information

Effective Date:

Business Name (Legal):

DBA:

Insured’s Name:

Date of Birth:

Type of Business Entity: CorporationLLCPartnershipIndividual/Sole Proprietor

If LLC, Number of Managers, LLC Members and Executive Officers:

If Corporation, Number of Executive Officers:

How did you hear about us?

2. Business Information

Business Address:

City:

State:

Zip:

Mailing Address:

City:

State:

Zip:

Website:

Phone:*

Email:*

Business Description:

Year Business Started:

FED Tax ID:

Days/Hours of Operation:

Number of Employees:

Expected Annual Sales:*

Year Building Constructed:

Do you offer Personal Training? YesNo

If Yes, Number of Personal Trainers:

Do you require personal trainers to carry their own Professional Liability Insurance policy? YesNo

3. Business Details

4. Building Details

Any of the following? (Check): Swimming PoolSaunaSteam roomHot tubTanning Beds

Is the business open 24/7? YesNo

If yes, how do customers access the building?

Number of Monthly Membership? (i.e., 1,200 Total Members/12 Months = # of Monthly Membership):

Responsible for Parking: YesNo

Number of Stories:

If Multiple, Story the Business on:

Total Sq. Ft. of Business:

Total Sq. Ft. of Building:

Year Updates Were Completed:

Plumbing:

Heating:

Electrical:

Roof:

Type:

*For Multiple locations, please contact us directly to review.

5. Prior Insurance

BUSINESS OWNERS POLICY APPLICATION

Affiliates and Partners