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Business Name: Form of Business:  Sole Proprietor  Corporation   Partnership  LLC Street Address:   City: State: Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code: Phone Number: Fax Number: Contact Email: Description of your business: Insurance Needed: Property General Liability Business Auto Workers’ Compensation Professional Liability Umbrella PROPERTY Building Coverage Limit: Business Personal Property Limit: Age of building: Construction: Brick    Frame Roof Material: Metal    Wood Sprinklers: Yes  No GENERAL LIABILITY Annual Payroll: Number of Employees: Limit of Liability required: 1 millon  500,000  300,000 Gross Receipts: BUSINESS AUTO Number of Vehicles:   • • If too many to list then scan and attach a copy of vehicle schedule page from current policy or fax it to 609-394-8288.       Year Make Model 1. 2. 3. WORKERS' COMPENSATION Classifications (from current policy*)       Description Number of Employees Annual Payroll 1. 2. 3. * If too many to list then scan and attach a copy of vehicle schedule page from current policy or fax it to 609-394-8288. PROFESSIONAL LIABILITY Limit of Liability required: 500,000  1 million  5 Million  Other Gross Revenue: Number of Professional Employees: Number of Other than Professional Employees: UMBRELLA Limit Required: 1 mil  5 million  10 Million  Other:

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