Applicant's Information

This is not to be completed

Business Name *	(DOING BUSINESS AS)	Contact's Name	Phone	Email *
BUSINESS NAME continued, ....list all related names of business
Address *	City	State	Zip	COUNTY

OWNERSHIP TYPE	YEAR BUS. STARTED	YEARS EXPERIENCE	BUSINESS OPERATED OUT OF A HOME	Township
Website		OWN ANY OTHER BUS.		Coverage Date Not Sure Of Date
In Business for Years or New		# Yrs Experience	Applicant Owns Other Business Yes No

Agent's Information

Agent Name

Contact

Contact Email

Contact Phone

General Liability Limits

Not Sure?

$500,000

$1,000,000

$2,000,000

$3,000,000

Yes No Non-Owned & Hired Automobile Liability

(This coverage may not be available via BUTWIN for this prospect)

(Please check our proposal to determine if the coverage has been included, and the premium charged)

Umbrella

Include total limit (General Liability + Umbrella) In the "General Liability" section above

List Underlying Insurance

If this section is not completed, the Umbrella may only be excess over the General Liability Insurance

Commercial Automobile
Insurance Carrier
Policy #
Policy Period
Auto Liablility Premuim $
Auto Liablility Limit
Yes No	NAMED INSURED on Commercial Auto Policy includes names not listed on this application
List Names

Workers Compensation
Insurance Carrier
Policy #
Policy Period
Premuim $
Limits
Yes No	NAMED INSURED on Commercial Auto Policy includes names not listed on this application
List Names

	# of vehicles
	Year / Make / Model
	Year / Make / Model
	Year / Make / Model
	Year / Make / Model
	Year / Make / Model
	Year / Make / Model

	Year / Make / Model
	Year / Make / Model
	Year / Make / Model


	" Other " Liability coverages
	Describe

Payroll, Sales, and Employee Count

Estimate if Possible, Please.

	Number of Workers	Annual Payrolls
Owners		$	Not Sure?
Office Staff		$	Not Sure?
All Other Full Time Employees		$	Not Sure?
All Other Part Time Employees		$	Not Sure?
Do you hire subcontractors	Yes No Not Sure?	Cost Of Subcontractors	Describe Work
Internet Sales	$	Not Sure?
Total Gross Receipts	$	Not Sure?

Contents, Buildings, Tools, etc...

YES NO Coverage Desired?

Number of Locations / Buildings

Workers Compensation Insurance

Fed Tax ID#		Unemployment Registration #
Total # of males		Total # of females
Entity has prior Workers Comp insurance	Yes No	If yes,	1 yr 2 yrs 3 yrs
	List different employee job functions	Annual payroll allocation $
		$
		$
		$
		$
Do we have a copy of current policy	Yes No	If Yes, submit with application
Does the owner want to be included	Yes No

Consultant Operations

What specifically are they paid to do?

What is the prospects finished product? Is it advice only?

Does the prospect target a specific industry?

Yes No

If yes, what industy?

Does the prospect have a brochure or website listing services provided?

Yes No

If yes, please remit?

Seasonal Tent / Lot Operations

Christmas Trees

Flowers

Pumpkin Patch

Describe Other Operations

Wholesaler Operations

Import any 'Product'

Yes No

Percentage of 'Product' imported

Describe what is imported

List countried imported from

Vendor - Fair/Show/Mall/Flea Mkt

Travel to multiple locations throughout the year

Yes No

Number of events per year

Indoors Outdoors

Do you sell any of the following products:

Yes No Unknown

Collectables and memorabilia (old), Drugs, Prepackaged & Non-prescription, Hearing Aids Hobby or craft, Optical Goods presription, Toys, any used or refurbished products, or any products manufactured by applicant or sold under applicant name or label(not including prepared food)

	Business Owners Policy / Package Policy
	General Liability		Special Events Policy
	Contents, Building, Tools		Employment Practices Liability
	Workers Compensation		Directors and Officers Liability
	Business Automobiles		Professional Liability
	Umbrella		N.Y. State DBL
	I'm Not Sure What I Need??		Cyber Liability

24hr. Operations	Consultant	Manufacturing	Seasonal Operations
Auto Body Shop	Computer Consult/Web/Tech	Manufacturers Rep	Seasonal Tent / Lot
Auto Repair	Deli/Convenience Store	Office - Professional	Services
Church	Habitational	Restaurants or Catering	Vendor - Fair/Show/Mall/Flea Mkt
Commercial Real Estate	In Home Business	Retail	Wholesale
Contractor / Construction

Carpet	%
Hardwood	%
Tile	%
Vinyl / Linoleum	%
Any Hardwood Floor Refinishing	Yes No

Maximum value per customers' car	$
Maximum total value of all customers' car on premises	$
Completion of this section is required in order to include Garage Liability and Garagekeepers Legal Liability Coverage
24 hour operation?	Yes No
Do we directly perform Towing & Roadside assistance?	Yes No
Gasoline sales?	Yes No
More than 25% of receipts from Tire Sales?	Yes No
More than 25% of receipts from Convenience Store sales?	Yes No
Boat work?	Yes No
Own dealer plates?	Yes No
Emergency vehicle repair?	Yes No
Sell/rent/lease/loan vehicles, trailers, or tools to others?	Yes No
Perform tire retreading?	Yes No
Install trailer hitches?	Yes No
Work on race cars ?	Yes No
Sponsor racing teams?	Yes No
Self service bay rentals offered ?	Yes No
Auto wreckage operations ?	Yes No
Painting?	Yes No	if yes, % of receipts: %
Is painting performed in NFPA-33 approved spray booths?	Yes No
Automobile restoration or customization?	Yes No	Explain :
Does the prospect undertake parking/garaging operations?	Yes No
Guard dog on premises?	Yes No
Customers allowed in the shop area at any time ?	Yes No
Work performed on any vehicles over 20,000 pounds gross vehicle weight ?	Yes No
Is there at leas 1 ASE mechanic are on duty at all times?	Yes No

Any hospitals, homes for the aged, infirmaries, orphanages, rehab services, sanitariums, convalescent homes, asylums, or newspaper/web publishing (other than church bulletins) associated with the church?		Yes No
Day care operations, other than used during religious service?		Yes No
Cemetery at the premises?		Yes No
Cooking on the premises?		Yes No
	If yes, grills ?	Yes No
	If yes, fryer ?	Yes No
Thrift-shop operation in the church?		Yes No
Premises rented out to any other functions?		Yes No
Gym on premises?		Yes No
Residence on premises?		Yes No
Playground on premises?		Yes No
Homeless shelter on premises?		Yes No
School (k-12) on premises?		Yes No
	If yes, lease or own buses or vans ?	Yes No
	If yes, conduct/sponsor interscholastic sports ?	Yes No
	If yes, conduct/sponsor travel or overnight trips ?	Yes No
Own or operate camps?		Yes No
For any child or youth activity, are 2 adults always present?		Yes No
Do they sponsor any outside functions?		Yes No
	If yes, provide details regarding annual events ?
Is the building considered a historical landmark		Yes No
How many members?


Yes No Hired to perform any: Cleaning, Installation, Landscaping, Janitorial or any other type of Contracting work		Describe Other Operations

Licensed	Yes No
More than 5% of work Performed Outdoors	Yes No
Alarm or Video Security Work	Yes No

Backhoe work	Yes No
Tree Pruning, involving Climbing	Yes No
Stump Removal	Yes No
Spraying	Yes No
(if Yes to Spraying) Greater than 25% of receipts	Yes No

Chimney work	Yes No
Backhoe work	Yes No
Foundation work	Yes No
(If Yes To Foundation work) Pouring Only	Yes No
Digging depth, deeper than 3 ft	Yes No
Street / Road work performed	Yes No

Licensed	Yes No
Electric Snaking of Pipe more than 5% of Sales	Yes No
Exterior Sewer or Septic work	Yes No
LPG work	Yes No
Boiler work	Yes No
Fire Sprinklers	Yes No
Below Grade work	Yes No
Digging Depth, deeper than 3 ft	Yes No
More than 5% of work Performed Outdoors	Yes No

Incidental, as respects other work being performed	Yes No
New Roofing	Yes No
Replacement / Tear-Off Roofing	Yes No
Hot Tar	Yes No

Consulting work?	Yes No	If yes, describe:
		If yes, advice only?: Yes No
Website Design?	Yes No
Website Hosting?	Yes No
Website data hosting?	Yes No
Hardware Installation & Repair?	Yes No
Software Installation & Support?	Yes No
Software development?	Yes No
Programming?	Yes No	If yes, describe:
Any specific industries targeted?	Yes No	If yes, describe:
Hardware manufacturing?	Yes No

24 hour operation?	Yes No
Gas station on the premises?	Yes No
Guard dog on premises?	Yes No
Delivery Services?	Yes No	If yes, By bike By Foot By vehicle Catering delivery

Table Seating?	Yes No	If yes, maximum seating capacity:
Table Service?	Yes No

Cooking on the premises?	Yes No	If yes, Grills Fryer

Hood/Duct System?	Yes No	Cleaning Contract ?	Yes No	How often cleaned
Ansul System?	Yes No	Cleaning Contract ?	Yes No	How often cleaned

Experience in restaurant industry		Years
Years in business at this location		Years
Is owner active in the management of the restaurant on a daily basis?		Yes No
Seasonal Operation?		Yes No	If yes, describe:
Dance Floor?		Yes No
Boat Dock?		Yes No
Lodging?		Yes No
Table Top Cooking?		Yes No
Seating?		Yes No	If yes, seating capacity:
			seating area:	square feet
			Table top cooking:	Yes No

Table Service?		Yes No	If yes, how many tables
Bar?		Yes No	If yes, bar capacity
			If yes, are servers 'TIPS' trained	Yes No

Delivery Services?		Yes No	If yes, By Bike By Foot By Vehicle
	If yes, Catering Delivery	Yes No	If yes, percentage receipts form catering %

Entertainment?		Yes No	If yes, describe (piano, band, DJ)
			How many nights a week

Are there any pool tables?		Yes No	How many pool tables

Other entertainment devices? (i.e., dartboards, video games)		Yes No	If yes, list

Hours of operation
Percentage of recipts from alcohol		%
What time is serving stopped?		Food Alcohol
Member of state restaurant assoc ?		Yes No
Hood/Duct System?		Yes No	Cleaning Contract Yes No How often cleaned
Ansul System?		Yes No	Cleaning Contract Yes No How often cleaned

Insured's Name*	EIN	SS#	DOB
Home Address	*Financial Responsibility will be ordered on all all risks. For a corporation or partnership, use the name of the President, CEO or partner responsible for the daily operations of the business.
Prior Insurance Carrier	BI Limits	Inception / Effective Date	Cancel / Expiration Date
Prior Auto Policy Number	Does Insured Have a GL or BOP Policy	Yes No
NOTE In some states, we charge $25 for each Additional Insured and / or Waiver or Subrogation.

Aluminum / Vinyl	%
Masonry / Stone	%

Vehicle Information	Vehicle #1	Vehicle #2	Vehicle #3
Year / Make / Model
Vehicle Type
Vehicle Identification Number (VIN)
Passenger Capacity
Numbers of Axles
Gross Vehicle Weight (if No VIN)
Trailer Hitch	Yes No	Yes No	Yes No
Use of Vehicle / Goods Hauled
Sites Per Day
Any Personal Use	Yes No	Yes No	Yes No
Garaging Zip Code
Total Stated Amount (included permanently attached equipment)
Radius of Operation (Maximum radius for Tractor-Trailers except Non-truck or PD only risks is 500
Driver Information	Drivers #1	Drivers #2	Drivers #3
Name
Marital Status	Married Single	Married Single	Married Single
DOB
Date CDL Issued
Driver License Number
State Issued
Filing Required (list type)
Coverage's - Limits / Deductibles (May vary by state)	Vehicle #1	Vehicle #2	Vehicle #3
BI / PD
UM / UIM
PIP
Medical Payments
Comprehensive or F&T w/CAC
Collision
On-Hook Towing
Non-Trucking / Bobtail / Contingent Liability
Non-Owned (include # of Employees)
Hired Auto (include annual cost)
Garagekeeper's Legal Liability
Trailer Interchange (includes # of trailers)

Business Description

Select all Operations that may apply to your business

Applicant's Information

Agent's Information

Contractor's Operations (Should Total 100%)

General Information - CONTRACTORS (Select all that Apply)

General Liability Limits

Umbrella

List Underlying Insurance

" Other " Liability coverages

Payroll, Sales, and Employee Count

Number of Workers

Annual Payrolls

Internet Sales

Total Gross Receipts

Contents, Buildings, Tools, etc...

Location 1

LIMITS

Property Info

Building Info

Location 2

LIMITS

Property Info

Building Info

Location 3

LIMITS

Property Info

Building Info

Location 4

LIMITS

Property Info

Building Info

Workers Compensation Insurance

Auto Repair/Auto Body Shop Operations

Church Operations

Consultant Operations

Computer Consultant/Tech/Web

Deli/Convenience Store Operations

Seasonal Tent / Lot Operations

Food Operations

Wholesaler Operations

Vendor - Fair/Show/Mall/Flea Mkt

Special Events Coverage

Event Information

Events Dates & Times

Facility/Venue Information

Business Automobiles

Liability Limits

Vehicle Information

Driver Information

Coverage's - Limits / Deductibles

Policy & Claims History

Anything else you would like us to know....?