Signarama Insurance Form - Cennairus Insurance

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Please select what lines of coverage you would like to obtain quotes for

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Business Information

Do you have an insurance agent currently working on quotes for you? *

Agent Name *

Agent Phone *

Agent Email *

What insurance companies have they provided quotes from?

Legal Business Name *

Entity Type *

Federal Tax ID Number *

If FEIN not obtained yet, please provide Social Security Number.

Location Address *

City

State

Zip Code

Years in Business *

Contact Number *

Contact Person *

Email Address *

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Owners

Owner Name *

Title *

Ownership % *

Coverage? *

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Employee

Job Description/ Class Code *

Number of employees *

Estimated Annual Payroll *

Please Explain Your Job Description or Class Code:

Do you currently have insurance coverage in force? *

Effective Date

Please attached all loss runs

Maximum file size: 16 MB

Do you Installs Signs? *

What is the Max. Height?

What percentage of installation is performed?

Do you hire subcontractors and/or independent contractors? *

What is the percentage?

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Building Information

Do you Own or Lease? *

Are you required to have building coverage? *

What is the amount?

Year Building was Built? *

Has the roof been updated? *

If yes, what year?

Number of Stories: *

Sprinkler? *

Square footage *

Central Burglar Alarm? *

Business Personal Property Coverage Amount (Covers Equipment, Furniture, Fixtures and Inventory that you Own) *

What is the amount of Coverage?

Landlord Name

Landlord Address

City

State

Zip Code

Hired and non-owned auto (HNOA) ? *

Insurance covers liability for damages caused by vehicles used for business, even if the business doesn’t own the vehicles. This includes vehicles that are rented, leased, or borrowed, as well as employees’ personal vehicles used for business.

Please Upload your Landlords Lease requirements

Maximum file size: 16 MB

GL Limits *

1M per Occurrence/2M Aggregate

2M per Occurrence/2M Aggregate

3M Per Occurrence/4M Aggregate

Estimated Annual Revenue *