A Service of Supple-Merrill & Driscoll, Inc.




 Professional Small Business Package Application Instructions

  1. Please complete and submit this online application for a free, no-obligation quote.

  2. Please be sure to provide all required information in order to receive a quotation. 


  Program Information

This is a secure application.  Strong cryptography is implemented via the Secure Sockets Layer protocol.  Our Privacy Policy.

  PDF Application (Coming Soon)


( indicates required information)

Applicant Information

Name of Company / Organization:

Full Name of Contact:
Street Address:
City, State: ,
Zip/Postal Code:


We will never rent, sell, or share your email address.

Applicant Type:





Select the classification that best describes the type of business.

Description of Business / Operations:

Clearly describe the operations of the business.

Date Established:

The date the business was established.  For start-ups, use today.


Business Details

Exposure Questions

What is your estimated gross sales for the next 12 months?

(Include all your company's locations)

Gross sales are the total sales that a business received from the products and services that it sells before deducting customer discounts, returned merchandise and allowances for doubtful accounts.

What is your estimated payroll expense for the next 12 months

for yourself, your full-time, part-time and temporary employees?

(Do not include subcontractors)

Including yourself, how many full-time, part-time and

temporary employees does your business have?

(Do not include subcontractors)

Approximately how many square feet does your

businesses occupy at this location?

General Statements

1) Does your business use a written contract or statement of work?
2) Is your business operated out of your home? Yes  No
3) Your business does not conduct any of the following activities:

a. Automotive Repair or Sales

b. Food Service / Restaurant Operations

c. Medical Services

d. Retail Operations

Note: This does not include your activities in any of these industries.

I Agree  I Disagree

4) Your business is not controlled or owned by any

other firm, corporation or entity.

I Agree  I Disagree

5) For the entire period of time that you have owned and controlled the

business, you have not sold, purchased or acquired, discontinued, merged

into or consolidated with another business.

I Agree  I Disagree
7) Does your business conduct any of the following activities?

a. Manufacture, design, or assist in the design of any hardware or components. (This does not include electronic devices)
b. Create, support, or work on software that executes securities transactions, makes medical diagnoses, or is involved in manufacturing or process control.
c. Own, host, or run any website that contains any pornographic materials or user generated content.
d. Own, or manage a social networking or auction website. (This does not apply to third-party sites where you offer hosting services only.)
e. Operate as a Voice Over IP Service Provider (This does not apply to use of a third-party VOIP service provider to conduct your own business's telephone calls.)

Yes  No

Tangible Goods or Products Questions

1) Do you or your business supply, manufacture,

or distribute any tangible goods or products?

Yes  No

2) Does your business perform any design, construction, installation,

removal, or physical repair of any property or tangible good?

Yes  No

Which of the following does your business implement?

1) Customer sign-off on deliverables?

2) Dedicated customer support?

3) Contracts with indemnification clauses in your favor?


Insurance History

Has your business ever had any commercial insurance cancelled or rescinded?

Yes  No

Based upon your knowledge and the knowledge of your businessís current and past partners, officers, directors and employees, during the last five years a third party has never made a claim against your business and you do not know of any reason why someone may make a claim.

I Agree  I Disagree

Do you currently have an insurance policy in effect for the coverage requested?

 Yes  No


Policy Term

Coverage Term - Annual Policy Period:

Effective Date


General Liability 

Each Occurrence / General Aggregate:

Certificates / Blanket Additional Insureds:


City / Other Special Certificates:

Waiver of Subrogation:

Primary & Non-Contributory Wording - Only if Required by Locations and Vendors



Errors & Omissions

Each Occurrence / General Aggregate:

Coverage Basis: Claims Made

Additional Insured Endorsement:

Waiver of Subrogation:

Primary & Non-Contributory Wording


Inland Marine

Electronic Data Processing Hardware & Software (owned, leased and rented):

Electronic Data Processing Hardware & Software - Maximum per item:

Business Income / Extra Expense:
Property in Transit and temporarily within other premises:
Detrimental Code (Aggregate / Occurrence):



Workers' Compensation


Waiver of Subrogation:

Primary & Non-Contributory Wording

All States Endorsement:


Other Than Monopolistic States

Identification Number:

An identification number  is required when binding Workers' Compensation coverage.

Payroll by Class Codes:

# Full Time (W2) # Part Time (1099) Total Payroll

9154 - Crew

If Any

Officers Names:

Full Name  Title

Workers compensation coverage is not provided for officers & owners.

Enter the first name, last name and title for each officer/owner.

Exclusions of coverage for stunts and hazardous activities will apply.







Terms and Conditions

Please carefully review the Terms and Conditions below:

  • Please read all exclusions indicated on quotation.

  • The quotation received is not binding on the Insurer in any way.

  • By clicking 'Submit Application' you are not agreeing to purchase coverage.  Via email, you will receive a free, no-obligation insurance quotation.

  • Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects the person to criminal and (NY: substantial) civil penalties. (Not applicable in CO, HI, NE, OH, OK, OR, VT). In DC, LA, ME, TN and VA, insurance benefits may also be denied.
  • Please note that once coverage is bound, the policy cannot be cancelled.

  • The insurance quotation will be based solely on the coverages and limits selected on this application.

  • Please ask your Supple-Merrill & Driscoll, Inc. representative to explain coverage details, exclusions, limits or other provisions of any insurance policy.

Type your name below, to indicate that you have read

and accepted the Terms and Conditions above:





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