Commercial Insurance Application - Acova Insurance Agency

Full Name*

First Last

Company Name

Email*

Phone*

Mailing Address

Street Address City State ZIP Code

Business Information

Applicant is:

Specific Type of Business

Years in Business

If Less Then 3 yrs Prev Experience

Employers Federal ID#

Professional Credentials - Affliations

Locations

Location #1

Location #2

Property Section - Non-Inventory

Building

Leasehold Improvements

Furniture & Fixtures

Computer/Phone Systems

Property Section - Inventory

Scheduled Inventory Total Value

Non-Scheduled Inventory Total Value

Maximum Value Unnamed loc's USA

Maximum Value Domestic Transit

Maximum Value On Exhibition

Do you have a Peak Season? If so how much more inventory/sales do you have?

Deductibles

Miscellaneous Property Issues

Plate Glass Coverage

Yes
No

Exterior Sign or Awning

Yes
No

Hold Up (Money & Securities)

Yes
No

Employee Theft

Yes
No

Back Up Of Sewers & Drains

Yes
No

Earthquake

Yes
No

Flood

Yes
No

Systems Breakdown

Yes
No

Comprehensive Liability

Primary Liability

Additional Liability Coverage

Employment Related Practices

Employee Benefits Liability

Umbrella - Excess Liability

Basic Rating Information

Operation	Prior Year Gross Sales	12 Month Projection - Gross Sales