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  • Effective Date Requested:*
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  • Any Delivery?*
  • Foreclosures, repossessions, judgments, liens or bankruptcy in past 5 years?*
  • Any foreign products sold or distributed?*
  • Does Applicant put their own name on the products?*
  • Any policy declined, cancelled or non-renewed?*
  • Formal safety program in place?*
  • Any known claims or losses?*
  • Are Subcontractors used?*
  • Is Applicant engaged in any other type of business?*
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  • Are Health Plans provided?*

  • *Complete all items in sections for which quote is requested.

    **Please provide loss run report for past five years. They will be required to bind unless this is a new venture or no prior insurance. (Loss Run Report Forms located on website)
     

    NOTE : Any quotation provided via this application is subject to the terms and conditions of the specified insurance company forms currently in use, including any amendatory endorsements and/or exclusions. THE QUOTATION MAY NOT CONFORM TO THE TERMS AND CONDITIONS REQUESTED. It is the responsibility of the retail insurance broker to review the terms of any quotation carefully with your Insured. Insurance Solutions Pacific Coast, Inc., disclaims any responsibility for any differences between the terms quoted and the terms originally requested.

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