Business Insurance Request Form - The Holden Agency (888) 722-1582

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Type of Business *

Your Name *

First

Last

Phone *

Email *

Legal Business Name and Doing Business As *

Will appear on policy

Year Business Established *

Type of Insurance Needed *

Business Owners Policy
General Liability
Workers Compensation
Sexual Abuse & Misconduct
Professional Liability
Other

Select all that apply

Primary Location Address *

Address Line 1

Address Line 2

City

State

Zip Code

Is your permanent address the same as your business address? *

Permanent Business Address Other Than Business Address

Address Line 1

Address Line 2

City

State

Zip Code

Is your mailing address the same as your business address? *

material? your business,

Mailing Address Other Than Business Address

Address Line 1

Address Line 2

City

State

Zip Code

What best describes your business's ownership structure? *

Does your business rent or own any permanent location outside of the state? *

Number of owners (members): *

Number of employees: *

Do not include owners, subcontractors, or independent contractors

Total number of owners and employees: *

Expected subcontractor payroll in the next 12 months: *

Include payroll for all cash workers and 1099 contractors.

Do you have all licenses required to operate your business? *

Have you ever had a business license suspended or revoked? *

Has your commercial insurance coverage been canceled, revoked, or non-renewed in the last 3 years? *

Other than cancellation for non-payment or non-renewal for discontinuation of program

Has your business, or any of its officers, owners, or partners: *

Been convicted of a felony in the past 5 years?
Declared bankruptcy in the past 3 years?
Had business-related lawsuits, mediations, or arbitrations filed against them?
Become aware of any losses, accidents, or circumstances that might give rise to a claim against this policy?
None of the above.

My business is located in: *

My home or apartment
A commercial space I rent
A commercial space I own
A commercial or residential space I own and rent to others

What is your expected total sales in the next 12 months? *

Are there multiple units (residential or commercial) in your building? *

What is your building's construction material? *

Frame (wood roof, floor, and walls) – most residential buildings
Joisted Masonry (wood roof and floor, brick walls) – small office and retail and some residential buildings
Non-combustible (steel roof, floor and walls) – warehouses and manufacturing
Masonry non-combustible (steel roof and columns, brick walls) – strip shopping centers and buildings over 3-4 stories
Modified fire-resistive (steel beams, pre-cast concrete or thick masonry walls)
Fire-resistive (reinforced concrete columns, thick concrete floors) – high rise buildings and parking garages

Do you have an insurance policy that provides coverage to your property from losses due to windstorm or hail? *

What year was this building built? *

Has the plumbing, electrical, and heating been updated in the past 15 years? *

What is the approximate square footage of your business? *

Is your building equipped with fire sprinklers? *

Select any protective devices you have: *

Local Burglar Alarm
Central Burglar Alarm
Local Fire Alarm
Central Fire Alarm
None of the Above

Does the building have any aluminum wiring? *

Is the building undergoing any structural renovation, demolition, or ground-up construction? *

What is your estimate for the cost of replacing existing or planned business property? *

These assets include: • Kitchen equipment • Furniture • Decorations • Average inventory • Electronics • Renovations you’ve made. Remember, this doesn’t include the value of the physical building.

Have there been any insurance claims filed by or against your business in the past three years? *

When would you like your coverage to start? *