Contact Name (Required):
Contact Phone Number (Required):
Email Address (Required):
 
 
Mailing Address:
City:
State:
ZIP:
Entity Name:
Location Address:
City:
State:
ZIP:
 
General Information
Type of Business (LLC, C Corp, S Corp):
Owner Name:% of Ownership:
Owner Name:% of Ownership:
Owner Name:% of Ownership:
Projected Revenues for the next 12 months:FEIN Number:Year Established:
Current Insurance Company:Renewal Date:
If start-up, please list business experience:
Franchise Designation:
 
Current Annual Premium (by line of coverage):
Package (Liability/Property):
Auto:
Workers Compensation:
Umbrella:
Other:
 
Workers Compensation
Estimated Payroll
StateCodePayroll
Example: MinnesotaExample: 8810 (office)Example: $30,000
Number of Employees:Max value of customer property in your care:
% of Residential work:% of Commercial work:
% of Interior Residential work:% of Interior Commercial work:
% of Exterior Residential work:% of Exterior Commercial work:
% of work subbed out:Workers Comp for owners:
Subcontractor Costs:
 
Auto Fleet List
YearMakeModelVIN
 
Driver List
Driver NameStateLicense NumberDOB
 
Property
Building:Building Limit:Contents Limit:
Construction Type:
Square Footage:Year Built:
Sprinklers?Alarm System?Smoke Detectors?
 
Umbrella
Do you carry an umbrella policy?Umbrella Limit:
 
Loss Prevention
Does your current broker help with your safety meetings?
If Yes, what type of loss prevention has he put in place?
Do you hold safety meetings at least once a month?
 



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The Loomis Company | 850 N Park Rd | Wyomissing, PA 19610 | 610.374.4040