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Type of Insurance:*

Auto
Home/Renters
Watercraft
Motorcycle/ATV/Off Road
Business
Special Events / Entertainment

Auto Insurance

List all operators (for members of the household)*

Full Name	Drivers License #	State Issued	License Status (Valid, Suspended, Permit, Not Licensed )	Date of Birth	Martial Status	Gender	Occupation

VIN # (all vehicles)*

Violations Last 5 Years (At fault or not at fault) (if none please type None)*

Full Name	Violation	Date

Claims Last 5 years (if none please type None)*

Full Name	Claim	Date

Primary Use*

Primary Residence*

Prior Insurance*

Yes
No

Carrier Name*

Coverage Limit

Expiration

Home/Renters Insurance

Property Address*

Street Address Address Line 2 City State ZIP Code

Amount of Personal*

Number of Household Members*

Prior Insurance*

Yes
No

Carrier Name*

Policy Term*

Annual
Semi-Annual

Coverage Limit

Expiration

Claims Last 5 Years (if none please type None)*

Watercraft

Type of Watercraft*

Year*

Make*

Model*

HIN #*

Hull Material*

Number of Motors*

Enhanced Performance Motor?*

Horsepower*

Maximum Speed*

Market Value*

Purchase Date*

Original Owner?*

Yes
No

Where is the boat stored during boating season?*

List all Operators*

First Name	Last Name	License Status (Valid, Suspended, Permit, Not Licensed)

Marital Status*

Birthdate*

Gender*

Violations Last 5 years (if none please type None)*

Full Name	Violation	Date

Claims Last 5 years (if none please type None)*

Full Name	Claim	Date

Prior Insurance?*

Yes
No

Association Affiliation*

Primary Residence*

Coverage Limit

Expiration

Motorcycle/ATV/Offroad

Type of vehicle*

VIN #*

Year/Make/Model*

Year	Make	Model	CC size	Purchase Year

Anti-Brakes?*

Yes
No

Vehicle Use*

MC Endorsement*

Years Riding Experience*

How often do you ride per week?*

Business

Name of the Business*

When the business started / will start*

Description of Business*

Business Address*

Street Address Address Line 2 City State ZIP Code

FEIN #*

List owners of business*

First Name	Last Name

Do you lease or own the occupied space?*

Lease
Own

Lease Agreement Upload*

Year building was constructed*

Square footage of occupied building*

Estimated annual revenue*

Number of employees*

Estimated annual payroll*

Please list the type of employees, part time or full time – How many of each and what type of position for each? For example, one part time receptionist and 4 full time hairstylists.*

Type of Employee	Number of type	Part-time /Full-time

Will products, clothing or accessories be sold?*

Yes
No

Will you have any liquor or food services or for sale?*

Yes
No

What is the total value of business property (including phones, computers, hair products and or styling equipment)?*

Special Events / Entertainment

Name of event*

Event Beginning Date*

Event Ending Date*

Is there a charge per attendee participating?*

Yes
No

Event Description*

Estimated Income*

Any overnight stays?*

Yes
No

Event Beginning Time*

: HH

MM

Event Ending Time*

: HH

MM

Location Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Square footage of occupied areas*

Anticipated # of participants per session ( if more than one session):*

Session #	Number of People

Number of Staff ( please note if they are paid or volunteer)*

Number of Staff	Paid / Volunteer

Are background checks done on staff members (paid or volunteer)?*

Yes
No

If yes, Please provide the third party doing the checks*

Any professional entertainers/athletes involved during this event?*

Yes
No

Is liquor involved?*

Yes
No

if so, is there a cost per drink?*

Yes
No

Please provide a website and/or copy of a flyer promoting the event, if applicable

Attachments

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Step 1 of 2

Auto Insurance

Home/Renters Insurance

Watercraft

Motorcycle/ATV/Offroad

Business

Special Events / Entertainment