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Online Application

Please complete all of the fields as accurately as possible. Additional information may be required (we will contact you).

By completing this application you have given right to run a credit check, if needed, and any check will ONLY be used for underwriting purposes. An underwriter will contact you within 24 hours.

Thank you for your interest!

BUSINESS INFORMATION
Business Name
Address:
City
State
Zip
Email
Business Phone:
Type of Business:
Federal Employer ID # :
Legal Entity:(LLC, INC, DBA ETC)
Date Business was established
   POLICY INFORMATION
Business Liability Limit
Construction Type
Year Built
Area (square feet )
Proposed Effective Data of the Policy
Proposed Expiration Data Policy
Annual Sales/receipts at this location

Number of property and liability losses in the prior 3 completed policy years and in the current year to date

Do any of the locations individual property values exceed $15 million ?

Yes No
Do the total annual sales exceed $15 Million ? Yes No

Do any of the locations individual annual sales exceed $10 Millions ?

Yes No
Location /Building Information
Building Limit
Optional
Business Personal Property Limit
Optional
Fire Legal Limit
Optional
Number of Employees
Optional
Additional Comments
   

COMPLETION OF THIS FORM CONSTITUTES PERMISSION FOR WORLDWIDE INSURANCE SPECIALISTS INC. TO OBTAIN CONSUMER INFORMATION

 

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