Contact Name *

First Name

Last Name

Phone *

(###)

###

####

Business Mailing Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Business Location Address (If different from mailing)

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Type of Business *

CORPORATION

ESTATE

JOINT VENTURE

LIMITED LIABILITY COMPANY (LLC)

NON-PROFIT

PARTNERSHIP

SOLE PROPRIETOR

PROFESSIONAL ASSOCIATION

TRUST

OTHER

Date Business Began *

MM

DD

YYYY

Coverage Start Date

MM

DD

YYYY

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

Yes

No

Has your previous insurance coverage ever been Cancelled or Refused? *

Yes

No

Type of Coverage Requested *

General Liability

Business Owners Policy (BOP) (Includes Business Equipment)

Professional Liability

Cyber Liability

Business Equipment Coverage Limit *

$10,000

$15,000

$20,000

$25,000

$30,000

$40,000

$50,000

$75,000

$90,000

$100,000

DECLINE

Hired & Non-Owned Auto Liability Limit *

Liability Protection for any Leased, Rented or Borrowed Vehicles of the business

$100,000

$250,000

$500,000

$1,000,000

DECLINE

Is your business operated out of your home? *

Yes

No

Do you own or rent your space? *

Own

Rent

Do you or your business supply, manufacture, or distribute any tangible goods or products? *

Yes

No

Does your business perform any design, construction, installation, removal or physical repair or any property or tangible good? *

Yes

No

Does your business provide any of the following? *

Alcoholic beverages or products (serving, selling or sub-contracting)

Animal/Livestock feed

Any products requiring a prescription

Baby Food

Energy Drinks

Kava

NONE OF THESE

Does your business provide any of the following operations or services? *

Commercial Farming

Companies/operations not in compliance with county, state and federal food and safety regulations

Delivery other than catering services

Grocery stores or supermarkets

Health coaching

Importers - produce or dairy making up more than 20% of total sales

Importers - seafood, meat, poultry

Nutrition consulting

NONE OF THESE

The undersigned being authorized by and acting on behalf of the applicant and all persons or concerns seeking insurance, has read and understands this proposal and declares all statements set for herein are true, complete, and accurate. The undersigned further declares and represents that any occurrence or event taking place prior to the inception of the policy applied for which may render inaccurate, untrue, or incomplete any statement made herein will immediately be reported in writing to the insurer. The undersigned acknowledges and agrees that the submission and the insurer’s receipt of such report prior to the inception of the policy applied for is a condition precedent to coverage. It is understood and agreed that the completion of this application shall not be binding either to the Proposed Insured or to the Company until accepted by the Company or Companies. Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly provides false information in an application for insurance may be guilty of a crime and may be subject to civil fines and criminal penalties. I certify that the above information is true and coverage is not applicable until accepted. *

I AGREE