Legal Business Name:
*
Business Address:
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Years in Business / Years of Experience:
*
Description of Operations (e.g., Specialty Foods Retailer):
*
Annual Gross Sales:
*
Total Annual Payroll:
*
Number of Employees (Full-time/Part-time):
*
Effective Date (Desired start of coverage):
*
Lines of Business:
*
Please Select
Commercial Insurance
Commercial Auto
Workers Comp
Business Owners Policy (BOP)
Commercial Property
General Liability
Cyber Liability
Professional Liability (E&O)
Employment Practices Liability (EPLI)
Inland Marine
Excess Liability & Umbrella
Auto & Fleet Solutions
Other
Building Details:
Construction Type:
*
Year Built:
*
Sprinklers:
*
Yes
No
Business Personal Property (BPP) (Total value of equipment, fixed assets, and appliances):
*
Spoilage Coverage (Requirement and amount)
*
Claims History:
Have you had any claims in the last 5 years?:
*
Yes
No
Additional Comments:
Landlord/Additional Insured:
*
YES
NO
Name:
Email:
Phone:
Primary Contact Info:
Name:
*
Email:
*
Phone:
*
Submit
Please email ACORD forms, Policy Documents, and Loss Runs directly to
info@fimsassurance.com
Should be Empty: