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Insurance shopping can be difficult, so we designed a website to make the process easier. Choose the coverage lines that are best for your business. Not sure what you need, that’s ok, get started by completing the application form, and we’ll step in to help you complete the process.

Desired effective date

State of Coverage

Legal Status

Applicant Name- The name of the business/entity requesting coverage.

DBA Name/T/A Type

DBA Name/ T/A if applicable

Federal Employment Identification Number

Year Business Began

Brief Description of Business

Mailing Address

Address Line 1

Address Line 2

City

State

Zip Code

Is the physical address the same as the mailing address?

Physical Address

Address Line 1

Address Line 2

City

State

Zip Code

What type of coverage you would like quotes for?

General Liability
Real Property
Commercial Auto
Professional Liability
Inland Marine
Workers Compensation

Work Comp- If blank, click Next

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Is this coverage for the businesses home state?

Yes
No, I need coverage for a different state

Checkboxes

Address belongs to my company
Address belongs to incident dispatch
I don't have an address in that state

Address in the state that coverage is needed

Address Line 1

Address Line 2

City

State

Zip Code

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Number of 7705 Employees- Medical personnel. Paramedics, EMT's, Ambulance Drivers, etc.

Annual Payroll for all 7705 employees

Number of 7710 Employees- Fireline personnel. Engines, Dozers, Water Tenders, etc.

Annual Payroll for all 7710 employees

Number of 8810 Employees- Clerical Administrative. Office Personnel

Annual Payroll for 8810 Employees

Do you have additional employees in class codes not listed that you want to cover? *

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What type of additional employees need coverage?

Annual Payroll for additional employees

Payroll Contact- If blank, click Next

Payroll Contact Name

First

Last

Phone

Inland Marine- If blank, click Next

Inland Marine Schedule

Please Describe Item (Year, Make, Model) Serial Number if Applicable, and state cash value.

Auto Coverage- If blank, click Next

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Business Auto Limit (Combined Single Limit:

Desired Comprehensive deductible amount

Uninsured/Underinsured Motorist Limit:

Desired Collision deductible amount

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Med Pay Limit:

$5,000
$10,000

What Is Medical Payments Coverage (MedPay)? Medical payments coverage is an add-on to an auto insurance policy that covers expenses related to vehicular accidents. Also called “MedPay,” it covers you and any passengers in your vehicle, any pedestrians you may injure, and you—if you are riding as a passenger in another vehicle or are injured by a vehicle as a pedestrian, bike rider, or public transportation rider.

Checkboxes if applicable, indicating your organization does have the following:

Mutual aid agreements?
Preventative maintenance program?
MVRs ordered prior to hire?
Driver training program?
Autos hired by applicant?

Does applicant own or operate any vehicles designed exclusively for hauling explosives, flammables or hazardous materials?

If Yes, provide details:

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Are officials, managers, employees or members allowed to take vehicles home?

Is any personal use of any vehicles by officials, managers, employees or members permitted?

Does applicant provide any type of non medical transportation services?

If Yes, provide details:

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Do you want Primary liability coverage for members’ personally owned and hired vehicles?

Are there any vehicles the organization does not own, but which are furnished for the organization’s regular use?

If Yes, be sure they’re listed in the schedule on the following page, and provide the owner’s information below as an additional insured / lessor.

Does the applicant have any Garage Liability or Garagekeeper’s exposure (for example, repairing the vehicles of others)?

Auto Schedule- If blank, click Next

Vehicle Schedule: Please list (Year, Make, Model), VIN#, and state cash value.

Additional insureds/ Lessors/ or Loss Payee's

If you have any, please give us their name, address, and which vehicle they are associated with.

Additional Locations- If blank, click Next

Is the Physical address from page 1 the only address/location you would like coverage for?

Add additional Address/location

Address Line 1

Address Line 2

City

State

Zip Code

Do need to list an additional address/location?

Add additional Address

Address Line 1

Address Line 2

City

State

Zip Code

Do need to list an additional address/location? (copy)

Add Address

Address Line 1

Address Line 2

City

State

Zip Code

Do need to list an additional address?

Professional Liability- If blank, click Next

Professional Liability Section:

Please State Profession

Please List: States in which you actively practice

Has your Certification/License in any state ever been (voluntaritly or otherwise) suspended, denied, revoked, restricted, or limited in any way?

List any association/ society/ memberships related to your profession

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Have you ever been insured by Mutual Assurance or Medical Assurance for Professional Liability?

Have you ever been diagnosed with or professionally advised to seek treatment for alcohol/drug abuse or addiction, mental illness or chronic physical illness?

Have you ever been charged with or convicted of a criminal offense?

Has your Professional Liabilty Insurance ever been cancelled, suspended, non-renewed, declined or issued only on special terms?

Are you a subsidiary of another entity or do you have any subsidiary?

Loss History

Loss History- Have their been any claims in the past 5 years?

Enter all claims (regardless of fault) or occurrences that may give rise to claims for the prior 5 years.

Date of Occurrence, Description of Claim, Date of Claim, Amount Paid, Amount Reserved, and status Open or Closed.

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