Name of Certificate Holder *

First Name

Last Name

Certificate Holder Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Does the Certificate Holder Need to Be an Additionally Insured? *

**Please Note: Blanket Additional Insured Endorsement Will Be Used Unless Otherwise Specified Or Not Offered By The Carrier**

Yes

No

Unsure

Certificate Holders Relationship to Insured *

Property Owner

General Contractor

Landlord

Municipality/Permit

CSLB

Other

Job Location Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Project Start Date *

MM

DD

YYYY

Is this Certificate for Multiple Projects? *

Yes

No

Owners Name *

First Name

Last Name

Phone

(###)

###

####

Mailing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Do you hold any professional licenses?

Yes

No

Entity Type *

Corporation

Partnership

Individual

Other

Which of the following best describes your business? *

Office

Retail

Wholesale

Service

Restaurant / Bar

Technology

Contractor

Manufacturing

Other

Do You Currently Have a Business Owners Policy?

Yes

No

Policy Expiration

MM

DD

YYYY

Have You Had Any Claims? *

Yes

No

If You Answered Yes, What is the Date of the Claim?

MM

DD

YYYY

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Own or Rent?

Own

Rent

Do You Have a Fire Alarm? *

Yes

No

Do You Have a Security Alarm? *

Yes

No

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Own or Rent

Own

Rent

Do You Have a Fire Alarm?

Yes

No

Do You Have a Security Alarm?

Yes

No

Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Do you require any specific types of Additional Insured Endorsements?

Yes

No

Do you require a minimum AM Best rating of your insurance company?

Yes

No

You are the:

Select 1

Owner

Owner/ Builder

General Contractor

Spec Builder/ Developer

Does the Contractor carry General Liability Insurance?

Yes

No

Any claims in the last five years?

Yes

No

Address of property under construction

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Project is:

Commercial

Residential

Ground up / New Construction

Renovation / Remodel

Mixed-Use

Estimated Start Date

MM

DD

YYYY

Estimated Completion Date

MM

DD

YYYY

Frame - Walls are constructed of wood or other combustible materials, including when combined with other material such as brick veneer, stone veneer, wood ironclad or stone on wood.

Masonry Joist - Walls are constructed of masonry materials such as clay, adobe, brick, gypsum block, cinder block, hollow concrete block, stone, tile, glass block or other similar material and where the floors and/ or roof are combustible

Non Combustible - Walls/ Floors/ Roof are constructed of and supported by metal, asbestos, gypsum or other noncombustible material

Masonry Non Combustible - Walls are constructed of masonry materials of the type described in masonry joist above, but with the floor and roof constructed of metal or other noncombustible material

Fire Resistive - Walls/ Floors/ Roof are constructed of fire resistive materials having a resistance rating of not less than two hours.

Site Security

Fenced

Lighting

Watchman Services

Is debris removed from the site in regular intervals?

Yes

No

Is the site in a brush area

Yes

No

Contact Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date Business Started

MM

DD

YYYY

Do you hold any professional licenses?

Yes

No

Policy Expiration Date

MM

DD

YYYY

Name

First Name

Last Name

Date of Birth

MM

DD

YYYY

Married?

Yes

No

Any known moving violations?

Yes

No

At fault accidents?

Yes

No

Liability Limits

$1,000,000

$750,000

$500,000

$300,000

$250,000

$100,000

$75,000

$50,000

Minimum State Requirements

Medical Payments

$5,000

$2,000

$1,000

$500

No Coverage

Uninsured Motorist – Bodily Injury

$1,000,000 / $1,000,000

$7500,000 / $750,000

$500,000 / $500,000

$300,000 / $300,000

$250,000 / $250,000

$100,000 / $100,000

$75,000 / $75,000

$50,000 / $50,000

No Coverage

Uninsured Motorist – Property Damage

$3,500 / CDW

No Coverage

Physical Damage – Comp/Coll Deductible:

$2,500

$1,000

$500

$250

No Coverage

Do you own any vehicles not listed on this application?

Yes

No

Are any vehicles used for delivery?

Yes

No

Are any vehicles used for public transportation / livery?

Yes

No

Is personal use by employees permitted?

Yes

No

Is use by family members permitted?

Yes

No

Contact Name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Do you own any business licenses?

Yes

No

Name

First Name

Last Name

D.O.B.

MM

DD

YYYY

Name

First Name

Last Name

D.O.B.

MM

DD

YYYY

Name

First Name

Last Name

D.O.B.

MM

DD

YYYY

Name

First Name

Last Name

D.O.B.

MM

DD

YYYY

Name

First Name

Last Name

D.O.B.

MM

DD

YYYY

Name

First Name

Last Name

D.O.B.

MM

DD

YYYY

Name

First Name

Last Name

D.O.B.

MM

DD

YYYY

Name

First Name

Last Name

D.O.B.

MM

DD

YYYY

Name

First Name

Last Name

D.O.B.

MM

DD

YYYY

Name

First Name

Last Name

D.O.B.

MM

DD

YYYY

Liability Limit

$1,000,000

$750,000

$500,000

$300,000

$250,000

$100,000

$75,000

$50,000

Medical Payments

None / No Coverage

$5,000

$2,000

$1,000

$500

Uninsured Motorist – Bodily Injury

$1,000,000 / $1,000,000

$7500,000 / $750,000

$500,000 / $500,000

$300,000 / $300,000

$250,000 / $250,000

$100,000 / $100,000

$75,000 / $75,000

$50,000 / $50,000

Uninsured Motorist – Property Damage

No Coverage

$3,500 / Collision Deductible Waiver

Vehicle 1

$2,500

$1,000

$500

$250

No Coverage

Vehicle 2

$2,500

$1,000

$500

$250

No Coverage

Vehicle 3

$2,500

$1,000

$500

$250

No Coverage

Vehicle 4

$2,500

$1,000

$500

$250

No Coverage

Do you own any vehicles not listed on this application?

Yes

No

Do you have any reason to anticipate a claim?

Yes

No

Are any vehicles used for delivery?

Yes

No

Are any vehicles used for public transportation / livery?

Yes

No

Is personal use by employees permitted?

Yes

No

Is use by family members permitted?

Yes

No

Business Name *

First Name

Last Name

Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Physical Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Expiration Date

MM

DD

YYYY

Is your current carrier offering renewal?

Yes

No

Contact Name

First Name

Last Name

Phone

(###)

###

####

Policy Expiration Date

MM

DD

YYYY

No Roofing / All Roofing is Subcontracted

Name *

First Name

Last Name

Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Physical Address

If different from mailing address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone

(###)

###

####

Is this your primary residence?

Yes

No

Effective Date

MM

DD

YYYY

Date of Birth

MM

DD

YYYY

Replacement cost on contents?

Yes

No

Replacement Cost on the Dwelling?

Yes

No

In the last 5 years has the applicant had any one of the following?

Click all that apply

Foreclosure?

Bankruptcy?

Repossession?

None

Is this occupancy your..

Select one

Primary

Secondary

Rental

Secondary Rental

Construction Type: Frame

Masonry

Non-combustible

Heating

MM

DD

YYYY

Plumbing

MM

DD

YYYY

Electrical

MM

DD

YYYY

Roofing

MM

DD

YYYY

Construction Style

Ranch

Cape

Colonial

Other

Roof Type

Wood Shake/Shingle

Asphalt/Comp

Metal

Tile

Slate

Foundation Type

Concrete Slab

Concrete Block

Pilings/Stilts

Alarms/Devices

Select all that apply

Central Fire

Central Burglar

Smoke Detectors

Fire Sprinklers

If yes..

Select one

125%

150%

Owners Name *

First Name

Last Name

Phone

(###)

###

####

Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date the business started

MM

DD

YYYY

Exp. Date

MM

DD

YYYY

If yes, date of claim

MM

DD

YYYY

Which of the following best describes your interest in the propert?

Residential Real Estate Investor

Commercial Real Estate Investor

Property Manager

Commercial Property Owner

Homeowner

Lender

Other

Desired Coverage

Property & Liability

Liability Only

Property Only

Tenant Protection Only

Property Location Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Property Type:

Single Family

Multifamily (2-20 units)

Condo

Mobile/ Modular

Garage

Construction Type:

Frame

Joisted Masonry

Non-Combustible

Masonry Non-Combustible

Modified Fire Resistive

Fire Resistive

Other

Select One

Replacement Cost Valuation (RCV)

Actual Cash Valuation (ACV *considers depreciation)

If yes, select one

Knob/tube

Aluminum

Copper

Unknown

Loc 1 Occupancy

Self-Occupied

Occupied Rental

Renovation

Vacant

New Construction

Renovation Start Date

MM

DD

YYYY

Does the Lender require?

Lenders Loss Payee

Mortgagee

Additional Insured Endorsement

Physical Location Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Property Type

Single Family

Multifamily (2-20 units)

Condo

Mobile/ Modular

Garage

Construction Type

Frame

Joisted Masonry

Non-Combustible

Masonry Non-Combustible

Modified Fire Resistive

Fire Resistive

Other

Select One

Replacement Cost Valuation (RCV)

Actual Cash Valuation (ACV *considers depreciation)

If yes, select one

Knob/tube

Aluminum

Copper

Unknown

Loc 2 Occupancy

Self-Occupied

Occupied Rental

Renovation

Vacant

New Construction

Renovation Start Date

MM

DD

YYYY

Does the Lender require?

Lenders Loss Pay

Mortgagee

Additional Insured Endorsement

What type of structure is it?

Garage

Shed

Other

Today's Date

MM

DD

YYYY

Contact Name *

First Name

Last Name

Phone

(###)

###

####

Mailing Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Physical Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Date Business Started

MM

DD

YYYY

Have you had prior workers comp insurance?

Yes

No Prior Coverage

1 - Owner / Partner / Officer

First Name

Last Name

2 - Owner / Partner / Officer

First Name

Last Name

3 - Owner / Partner / Officer

First Name

Last Name

4 - Owner / Partner / Officer

First Name

Last Name