"*" indicates required fields

When do you want the policy to start?*

MM slash DD slash YYYY

Legal Business Name*

Entity Type*

DBA

Tax ID*

Mailing Address*

Street Address Address Line 2 City State ZIP Code

Primary Contact Information

Name*

First Last

Date of Birth*

Month

Day

Year

Email*

Phone*

Can we text you?*

Yes

Please visit our Privacy Policy regarding Texting/SMS communication.

Designated Financial Responsibility for Company?*

Yes

What is your role?*

Years of experience in this type of business*

How many years of management experience?*

Other Role*

Is there a Secondary business contact?

Yes

Secondary Contact Information

Secondary Contact: Name*

First Last

Secondary Contact: Date of Birth*

Month

Day

Year

Secondary Contact: Email*

Secondary Contact: Phone*

Secondary Contact: Role*

Secondary Contact: Years of experience in this type of business*

Secondary Contact: How many years of management experience?*

Secondary Contact: Other Role*

General Business Information

How many days per week is business open?*

Hours of Operation*

Is this a seasonal operation?*

Yes

What is the season? From & To*

Does the business have a safety program?*

Yes

Name of Safety Director*

Safety Director Phone

Safety Director Email

Does the business have a disaster plan?*

Yes

Name of Disaster Director*

Disaster Director Phone

Disaster Director Email

Describe Primary Business Operations*

Describe any secondary and/or incidental operations

Other Important People

Optionally include the Name and Phone of any additional important people. Examples include other owners/principals, decision makers, financial persons, legal persons, claims persons, etc.

Total Annual Payroll*

Property Information

Physical Address*

Street Address Address Line 2 City State ZIP Code

Does applicant own the building?*

Yes

Who owns the building?*

Is applicant contractually obligated to insured the building?*

Yes

If building sustains a major loss, would the applicant replace it with the same type of structure?*

Yes

Year Built*

Has there been updates to the Roof, Electrical, Heating, or Plumbing?*

Yes

Unsure

Roof Update Year

Electrical Update Year

Heating Update Year

Plumbing Update Year

Have any additions been made to the building?*

Yes

Please describe the addition and date it was completed

Business Personal Property

Describe your business personal property

Some example include: Tools, equipment, machinery, supplies, livestock, feed, grain, pesticides, fertilizers, office equipment, irrigation systems, etc.

Are detailed records kept of all business inventory, machinery, fixtures, or equipment, including their purchase date the price?

Yes

Are labels and inventory numbers assigned to all items?

Yes

Is the business personal property highly flammable?

Yes

Is business personal property susceptible to severe damage from any of the following?

(Check all that apply)

Smoke

Heat

Water

Temperature

Would the business personal property be damaged if heat, light, or power failed?

Yes

Describe what would be damaged and how quickly*

Will an alarm sound or another notification happen if the power fails or shuts off?

Yes

Are backup generators available?

Yes

Does the business repair vehicles on the premises?

Yes

Are flammable liquids such as paints, glues, and varnishes used and stored?

Yes

Does the business do welding or soldering on premises?

Yes

Is gasoline drained prior to any welding or soldering?

Yes

Describe any burglar alarm, or safe, or vault alarm systems

Tenant Leasing & Improvements

Please describe any improvements or betterments that have been added

What is the length of term of the lease?

What is the lease renewal option term?

Is the lease in writing?

Yes

What is the agreed upon monthly rent?

Downpayment or non-refundable advance to rent the space? (if applicable)

Value of improvements and betterments

Does the business occupy the premises?

Yes

Does the business sublet any or all of the premises?

Yes

Is the lease between the business and sub-lessee(s) in writing?

Yes

Business Income

Gross Annual Sales / Revenue*

Amount of continued monthly expenses during any business suspension?

How many days does business need to resume operations?

Will business net income equal its pre-loss levels as soon as operations resume?

Yes

How many days are needed before income returns to its pre-loss leve?

120

150

180

Describe a piece of equipment or type of operation that might force the business to suspend operations until it was replaced, repaired, or resumed.

Describe available backup systems that the business can use when there is an off-premises power outage.

Does business depend on specific customers in order to continue its operations?

Yes

Does business have a cooperation agreement with other that could reduce an income loss?

Yes

Please describe the agreement

Accounts Receivable

Average monthly amount of receivables over the past 12 months?*

Maximum monthly amount of receivables over the past 12 months?*

Where are the records of accounts receivables stored?

Are duplicates of records of receivables duplicated and stored separately?

Yes

How long are duplicates kept?

Livestock Information

Does the business have livestock?

Yes

Livestock

Primary type(s) of livestock?*

Describe other types of livestock on premises other than Primary livestock

Is livestock raised on premises?

Yes

Where barns built for the current type of livestock?

Yes

Are livestock allowed free range outside buildings?

Yes

What security measures are in place to protect such livestock?

Mobile Equipment Information

List of equipment, or total $ amount per equipment type

Where is equipment kept?

% On premises in barn

% On premises in yard

% Off premises in barn

% Off premises in yard

% Other

Is any equipment loaned to others?

Yes

Does the business borrow equipment from others?

Yes

General Liability

Describe business on-premises operations*

Describe business disposes of waste

Does the facility comply with National Fire Protection Association's (NFPA) Life Safety Code concerning the number, size, and arrangement of exits?*

Yes

Are employees instructed in proper evacuation procedures?*

Yes

Does management conduct regular fire drills?*

Yes

Does the business own, jointly own, hire, or lease any watercraft or aircraft?*

Yes

Does the business provide any type of child or adult care on premises?*

Yes

Is food handled on premises?*

Yes

Are food handlers required to use proper hygiene?*

Yes

Has the Board of Health cited the establishment?*

Yes

Does the business store cleaning materials in a separate area at a distance from the food storage area?*

Yes

Does the business conduct any agritainment on the premises?*

Yes

Percent of total revenue generated from agritainment?

Type(s) of agritainment offered

(Check all that apply)

Hay Rides

Pony Rides

Wine Tasting

Cornfield Maze

Harvest Festivals

Haunted House or Barn

Food to Table Meals

Weddings

Interactive Animals

Swimming

School Tours

Other

Other agritainment offered

Describe the background checks required for all employees who work with children

Does the business own or rent parking facilities that are available to clients, customers, employees, and/or the general public?*

Yes

Parking Lots and Sidewalks

Does business charge a parking fee?

Yes

Does business hire a towing company to remove vehicles parked on premises without permission?

Yes

Does business require a certificate of insurance from any towing company that provides services on premises?

Yes

Does business make arrangements to remove snow and ice from the parking facility and walkways?

Yes

Describe the parking facility(ies)

Proximity to business premises, approx. number of spaces, number of stories, length, width, etc.

Employees

Does the business employ migrant laborers?

Yes

Please describe the operation, duties, and duration of migrant employment

Do any employees travel outside the United States to work?

Yes

Do any employees telecommute or work from home?

Yes

Are any employees considered exempt from workers compensation in the jurisdiction where they work?

Yes

Are employees trained before operating any machinery or equipment?

Yes

Are employees trained in the proper way to clean machinery and equipment?

Yes

Employees Off-Premises

Do employees interact on a regular basis with customers off premises?

Yes

Do employees travel alone?

Yes

Are employees subject to criminal background checks?

Yes

Describe the procedure to train, monitor, and supervise all such off-premises employees

Subcontractors

Does business regularly use subcontractors?

Yes

Annual payroll for all subcontractors

Describe the type of work subcontractors perform

Describe procedures to monitor Certificates of Insurance

Does business have a written contract with each subcontractor?

Yes

What are subcontractors' required insurance limits?

Advertising Information

Does business advertise its products, goods, or services?

Yes

What media does the business use and percentage of overall advertising budget?

% Television

% Direct Mail

% Radio

% Signs

% Newspaper

% Magazine

% Internet

% Other

Website

Does business use an advertising firm and/or outside web designer?

Yes

If a product or service is defective or used improperly, describe the possible damage that could occur

Is a written quality control procedure in place?

Yes

Have health code violations occurred within the last 5 years?

Yes

Please explain health violation(s)*

Liquor

Does the business ever serve, sell, or furnish alcoholic beverages to employees, customers, or the general public?

Yes

Is the applicant in the business of selling, distributing, or serving liquor?

Yes

What precautions does the business take to prevent guests from driving when they are intoxicated?

Employee Benefits

Does the business provide benefits to its employees?

Yes

Type(s) of employee benefits offered

(Check all that apply)

Health

Life

Disability

Stock Purchase

Pension

401(k)

Workers Comp

Other

Describe other type of benefits

Are all benefits listed above available to all employees?

Yes

Identify the types of employees who do qualify and explain how the business advises its employees of their eligibility for benefits

What is the employee turnover rate?

Does the business termination procedure require that the terminated employee sign an agreement stating that available benefits have been explained?

Yes

Environmental Impairment

List the chemicals used in the business operations

Describe business waste disposal procedure

Describe any tank storage on business premises

Has there been a recent inspection of the premises for contamination and/or an environmental assessment of the operations?

Yes

When, Why, and Who conducted the inspection

Does the business know about any existing pollution problems?

Yes

Have there been pollution damage or claims that allege pollution damage during the last 10 years?

Yes

Has the business discontinued any process(es) or abandoned any underground tank(s)?

Yes

Describe precautions taken to prevent pollution

Vehicle(s)

How many vehicles of the following types does the business own or lease?

Private Passenger

Small Trucks

Medium Trucks

Heavy Trucks

Extra Heavy

Bus

Mobile Equipment

Farm Equipment

Are vehicles ever hired/rented?

Yes

Do vehicles ever travel to Canada or Mexico?

Yes

Do any vehicles ever transport livestock?

Yes

Does the applicant use tanker trucks to transport milk?

Yes

Are tankers cleaned and inspected after each delivery?

Yes

Are tankers clearly marked to identify contents in order to prevent contamination of the product?

Yes

Would you like to enter your vehicle(s) information now?*

Yes

That's ok. If you have vehicles to insure, your agent can gather this information from you later.

Vehicle 1

1. VIN*

1. Year

1. Make

1. Model

Add 2nd Vehicle?

Add Another Vehicle

Vehicle 2

2. VIN*

2. Year

2. Make

2. Model

Add 3rd Vehicle?

Add Another Vehicle

Vehicle 3

3. VIN*

3. Year

3. Make

3. Model

Add 4th Vehicle?

Add Another Vehicle

Vehicle 4

4. VIN*

4. Year

4. Make

4. Model

Add 5th Vehicle?

Add Another Vehicle

Vehicle 5

5. VIN*

5. Year

5. Make

5. Model

If you have more than 5 vehicles, we will reach out to you to gather the remaining ones.

Driver(s)

Do you have drivers that need to be insured?

Yes

Are business officers, partners, or employees furnished an automobile for their personal use?

Yes

Do individuals with a vehicle furnished by the business purchase auto insurance on vehicles they own personally?

Yes

Would you like to enter your driver(s) information now?

Includes list of names, date of births, drivers license #, and state of issuance

Yes

That's ok. If you have drivers that your business needs to insure, your agent can gather this information from you later.

Driver 1

1. Name

First Last

1. Date of Birth

MM slash DD slash YYYY

1. DL#

1. DL State

Add 2nd Driver?

Add Another Driver

Driver 2

2. Name

First Last

2. Date of Birth

MM slash DD slash YYYY

2. DL#

2. DL State

Add 3rd Driver?

Add Another Driver

Driver 3

3. Name

First Last

3. Date of Birth

MM slash DD slash YYYY

3. DL#

3. DL State

Add 4th Driver?

Add Another Driver

Driver 4

4. Name

First Last

4. Date of Birth

MM slash DD slash YYYY

4. DL#

4. DL State

Add 5th Driver?

Add Another Driver

Driver 5

5. Name

First Last

5. Date of Birth

MM slash DD slash YYYY

5. DL#

5. DL State

Add 6th Driver?

Add Another Driver

Driver 6

6. Name

First Last

6. Date of Birth

MM slash DD slash YYYY

6. DL#

6. DL State

Add 7th Driver?

Add Another Driver

Driver 7

7. Name

First Last

7. Date of Birth

MM slash DD slash YYYY

7. DL#

7. DL State

Add 8th Driver?

Add Another Driver

Driver 8

8. Name

First Last

8. Date of Birth

MM slash DD slash YYYY

8. DL#

8. DL State

Add 9th Driver?

Add Another Driver

Driver 9

9. Name

First Last

9. Date of Birth

MM slash DD slash YYYY

9. DL#

9. DL State

Add 10th Driver?

Add Another Driver

Driver 10

10. Name

First Last

10. Date of Birth

MM slash DD slash YYYY

10. DL#

10. DL State

If you have more than 10 drivers, your agent will reach out to you to gather the rest.

Wrapping Up

Do your business have current insurance or past insurance?*

Yes

1. Carrier Name

1. Policy Expiration Date

MM slash DD slash YYYY

2. Carrier Name

2. Policy Expiration Date

MM slash DD slash YYYY

3. Carrier Name

3. Policy Expiration Date

MM slash DD slash YYYY

Additional Comments

File Attachment(s)

Optionally attach any relevant documents. Some examples may include lease agreements, MVRs, vehicle or drivers lists, certifications, COI requirements, etc.

Drop files here or

Accepted file types: pdf, Max. file size: 2 MB.

Please let us know the best time to call and discuss your quote

Morning

Afternoon

Evening

Anytime

How were you referred to us?

Since we are family owned and appreciate referrals, we like to send referrals a gift card to say thank you.

All the above information is accurate and true to the best of my knowledge.*

Yes

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MJ Martinez Insurance Agency

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Primary Contact Information

Secondary Contact Information

General Business Information

Property Information

Business Personal Property

Tenant Leasing & Improvements

Business Income

Accounts Receivable

Livestock Information

Livestock

Mobile Equipment Information

General Liability

Parking Lots and Sidewalks

Employees

Employees Off-Premises

Subcontractors

Advertising Information

Liquor

Employee Benefits

Environmental Impairment

Vehicle(s)

Vehicle 1

Vehicle 2

Vehicle 3

Vehicle 4

Vehicle 5

Driver(s)

Driver 1

Driver 2

Driver 3

Driver 4

Driver 5

Driver 6

Driver 7

Driver 8

Driver 9

Driver 10

Wrapping Up

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