ProductionInsurance.com
  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:
Entity:

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

Email:

We will never rent, sell, or share your email address.
Website:
Applicant Type:

 

Operations
Operations:

 

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) Does your business use rented or non-owned vehicles

(e.g. an employee's car) for business purposes?

 Yes  No
3) Is your business operated out of your home? Yes  No
4) 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

5) Your business is not controlled or owned by any

other firm, corporation or entity.

 I Agree  I Disagree

6) 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 business’s 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:

 Included

City / Other Special Certificates:

Waiver of Subrogation:

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

Hired Auto And Non-Owned Auto Liability (Occurrence/Aggregate) - Sublimit:

Terrorism:

 

Errors & Omissions

Each Occurrence / General Aggregate:
Retention:
Coverage Basis: Claims Made

Additional Insured Endorsement:

 Included
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):

Terrorism:

 

Workers' Compensation

Limits:

Waiver of Subrogation:

Primary & Non-Contributory Wording

All States Endorsement:

Included

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.

 

Notes

 

 

 

 

Terms and Conditions
 
  • I represent that this application form has been completed after proper inquiry and, based on this inquiry, I represent the application contents are true, accurate, and not misleading.
  • I represent that I understand and agree that if any of the contents of this application are intentionally untrue, inaccurate, or misleading, in any material respect, or if I fail to notify the insurance company of additional information that might render the contents of this application untrue, inaccurate, or misleading, in any material respect, then the insurance company is entitled to rescind any policy issued pursuant to this application.
  • 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 civil penalties.
  • I represent that I understand and agree that this application and all materials submitted in connection with this application are incorporated into and form the basis of any policy issued by the insurance company pursuant to this application.
  • I represent that by signing this application I am representing that I am duly authorized to execute insurance contracts on behalf of the entity applying for this coverage and that all representations (whether verbal or written) made in connection with this application are made on behalf of and shall be fully binding upon such entity.
  • A quotation received is not binding on the Insurer in any way. 
  • By clicking 'Submit Application' you are not agreeing to purchase coverage.  If terms can be offered you will receive a free, no-obligation insurance quotation via email.  All quotes require underwriter’s approval and payment prior to binding.  Please read all exclusions indicated on the quotation.
  • 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 further explain coverage details, exclusions (including stunts and/or other hazardous activities), limits or other provisions of any insurance policy, or to request a sample policy form.

 

State Notifications

 

NOTICE TO ALASKA RESIDENT APPLICANTS: A person who knowingly and with the intent to injure, defraud, or deceive an insurance company files a claim containing false, incomplete, or misleading information is guilty of a felony.

NOTICE TO ARKANSAS RESIDENT APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance may be guilty of a crime and subject to fines and confinement in prison.

NOTICE TO CALIFORNIA RESIDENT APPLICANTS: For your protection California law requires the following to appear on this form. Any person who knowingly presents false or fraudulent claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in prison. Any person who knowingly files a statement of claim containing any false or misleading information is subject to criminal and civil penalties.

NOTICE TO COLORADO RESIDENT APPLICANTS: It is unlawful to knowingly provide false, incomplete or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policy holder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.

NOTICE TO DELAWARE RESIDENT APPLICANTS: Any person who knowingly, and with the intent to injure, defraud or deceive an insurer, files a statement of claim containing any false, incomplete or misleading information is guilty of a felony.  

NOTICE TO DISTRICT OF COLUMBIA RESIDENT APPLICANTS: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, any insurer may deny insurance benefits if false information materially related to a claim was provided by the applicant.

NOTICE TO FLORIDA RESIDENT APPLICANTS: Any person who knowingly and with intent to injure, defraud or deceive any insurer files a false statement of claim or an application) containing any false, incomplete or misleading information is guilty of a felony of the third degree.

NOTICE TO HAWAII RESIDENT APPLICANTS: For your protection, Hawaii law requires you to be informed that presenting a fraudulent claim for payment of a loss or benefit is a crime punish able by fines, imprisonment or both.

NOTICE TO IDAHO RESIDENT APPLICANTS: Any person who knowingly, and with the intent to defraud or deceive any false, incomplete or misleading information is guilty of a felony.

NOTICE TO INDIANA RESIDENT APPLICANTS: A person who knowingly and with the intent to defraud an insurer files a statement of claims containing any false, incomplete or misleading information commits a felony.

NOTICE TO KENTUCKY RESIDENT APPLICANTS: Any person who knowingly and with the intent to defraud an insurance company or other person files an application for insurance or statement of claim 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.

NOTICE TO LOUISIANA, MAINE AND TENNESSEE RESIDENT APPLICANTS: Any person who knowingly and with the intent to defraud any insurance company or another person, files a statement of claim contain 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, subject to criminal prosecution and civil penalties. Insurance benefits may also be denied.

NOTICE TO MINNESOTA RESIDENT APPLICANTS: A person who submits an application or files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.

NOTICE TO NEBRASKA RESIDENT APPLICANTS: Any person who knowingly presents false information in an application for insurance or viatical settlement contract is guilty of a crime and may be subject to fines and confinement in prison.

NOTICE TO NEVADA RESIDENT APPLICANTS: Pursuant to NRS 686A.291, any person who knowingly and willfully files a statement that contains any false, incomplete or misleading information concerning a material fact is guilty of a felony.

NOTICE TO NEW HAMPSHIRE RESIDENT APPLICANTS: Any person who, with the purpose to injure, defraud or deceive any insurance company, files a statement of claim containing any false, incomplete or misleading information is subject to prosecution and punishment for insurance fraud, as provided in RSA 638:20.

NOTICE TO NEW JERSEY RESIDENT APPLICANTS: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

NOTICE TO NEW MEXICO RESIDENT APPLICANTS: Any person who knowingly presents false information in an application for insurance is guilty of a crime and may be subject to civil fines and criminal penalties.

NOTICE TO NEW YORK RESIDENT APPLICANTS: Any persons who knowingly and with the intent to defraud any insurance company or other person files an application for insurance or statement of claim 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 shall also be subject to a civil penalty not to exceed five thousand dollars and the stated value of the claim for each such violation.

NOTICE TO OHIO RESIDENT APPLICANTS: Any person who, with the intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement is guilty of insurance fraud.

NOTICE TO OKLAHOMA RESIDENT APPLICANTS: WARNING: Any person who knowingly and with the intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.

NOTICE TO OREGON RESIDENT APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents materially false information in an application for insurance may be guilty of a crime and may be subject to fines and confinement in prison.

NOTICE TO PENNSYLVANIA RESIDENT APPLICANTS: Any person who knowingly and with the intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact thereto commits a fraudulent insurance act, which is a crime and subjects such a person to criminal and civil penalties.

NOTICE TO UTAH RESIDENT APPLICANTS: For your protection, Utah law requires the following to be included in this application: Any person who knowingly presents false or fraudulent underwriting information, files or causes to be filed a false or fraudulent claim for disability compensation or medical benefits, or submits a false or fraudulent report or billing for health care fees or other professional services is guilty of a crime and may be subject to fines and confinement in state prison.

NOTICE TO VIRGINIA RESIDENT APPLICANTS: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

NOTICE TO WASHINGTON RESIDENT APPLICANTS: It is a crime to knowingly provide false, incomplete, or misleading information to an insurance company for the purposes of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.

NOTICE TO WEST VIRGINIA RESIDENT APPLICANTS: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison

 

Type your name below, to indicate that you have read and accepted the Terms,

Conditions and State Notifications above:
 
 
Signature (Please type your first and last name) Date
   
Title  
 

 

 

  

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