JWCS Insurance Agency Inc Application for Business Insurance Current Carrier:Premium:X-Date: MM slash DD slash YYYY Need By Date: MM slash DD slash YYYY Business Name: Indv LLC LLC Corp Other Check Lines to Include is Quote: GL PROP IM BA WC HNOA PROF LQ FLD UM Dba:FEIN:Limit?Applicant InfoMailing Address:Contact Name:Phone Number:Year Business Started:If New: Years Experience:Email Address: Website:General Liability (will quote $1M/$2M Limits)Description of Operations:Annual Sales/Revenue:Annual Payroll:Subcontractor Cost: 0Property (Deductible $2500 GL/$5000 or higher for Property)(Based on $1.02 per sqft)Location Address:Year Built:Sq.ft:Sprink? Yes / No Yes No Updates Year?Const. Type# of Stories:BPP Limit:Building Limit:Mobile Equipment/Scheduled Limit:Mobile Equipment/Small Tools Limit:Business Auto (will quote full coverage with $500 comp/coll deductibles)1- Vehicle YearMakeModelValue1million CSL2- Vehicle YearMakeModelValueVIN1-Driver: NameDOB: MM slash DD slash YYYY State / DL# MM slash DD slash YYYY Married/single Married Single 1-Driver: NameDOB: MM slash DD slash YYYY State / DL# MM slash DD slash YYYY Married/single Married Single Workers Compensation (will quote $500K/$500K/$500K Limits)1-Owner/Officer: N/ASSN:% OwnershipIncl/Excl? Incl Excl 2-Owner/Officer: NameSSN:% OwnershipIncl/Excl? Incl Excl Class Code (or Description of Duties):Annual Payroll:# of EE’s:Class Code (or Description of Duties):Annual Payroll:# of EE’s:Please provide Loss Details and/or Additional Information (attach additional pages as needed)CAPTCHA
