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QUESTIONS?

If you have any questions, you can contact our underwriting department at 801-304-3705 or quotes@primeis.com.

All forms listed on this site have been prepared by Prime for the exclusive use by producers and policyholders of Prime and its affiliates. These forms are provided as a general reference guide only, and they may vary from policy forms actually issued. These sample forms do not constitute or replace the actual policy forms issued to any policyholder; accordingly, we strongly recommend that you consult with your legal counsel upon receiving any insurance forms or policies from Prime.

Step 1 of 10

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General Information
Proposed effective date:*
MM slash DD slash YYYY
Business name:*
Applicant's name:*
First Last
Applicant's mailing address:*
Address: City: State: Zip:
County:*
E-mail:*
Business telephone number:*
Fax:
Physical location of business (if different):
Population within 50 miles:*
Other locations used:
Configuration Required
Use the Nested Form and Summary Fields settings to choose the form and fields to display in this Nested Form field.
Please list any other names the business is or has been known by:
Contact person:*
First Last
Producer name:*
First Last
Producer phone number:*
Producer e-mail:*
Detailed description of business activities (specifically, and by location):*

Applicant is:*
- Individual
- Corporation
- Partnership
- Joint Venture
Is this a new business?*
- Yes
- No
Please list the owner(s) of the business applying for insurance and identify how many years experience the owner(s) has in this type of business:*
Please list the manager(s) of the business applyng for insurance and identify how many years experience the manager(s) has in this type of business:*
Annual payroll:*
Total number of employees:*
Full-time:*
Part-time:*

Please describe the business's drug policy and what the procedure is when an applicant or employee fails a drug test:*
Does your company have within its staff of employees a position whose job description deals with product liability, loss control, safety inspections, engineering, or other professional consultation advisory services?*
- Yes
- No
If yes, please tell us, Employee name:*
First Last
E-mail:*
Business telephone number :*
Fax:
Years with company:*
Employee's responsibilities:*

Insurance history
What is your current insurance carrier (or your last if no current provider)?*

Provide names for all insurance companies that have provided Applicant insurance for the last three years:*

Coverage:	Company name:	Expiration date:	Annual premium:

Has the Applicant or any predecessor ever had a claim?*
- Yes
- No
Attach a five year loss/claims history, including details.
Drop files here or

Max. file size: 25 MB.
Have you ever had any incident, event, occurrence, loss, or wrongful act which might give rise to a claim covered by this policy, prior to the inception of this policy?*
- Yes
- No
If yes, please explain:*
Has the Applicant, or anyoone on the Applicant's behalf, attempted to place this risk in standard markets?*
- Yes
- No
If the standard markets are declining placement, please explain why:*

Other Insurance

Please provide the following information for all other business-related insurance the Applicant currently carries.*

Coverage type	Company name	Expiration date	Annual premium

Desired Insurance
Per act/aggregate
- $50,000/$100,000
- $150,000/$300,000
- $250,000/$1,000,000
- $500,000/$1,000,000
Per person/per act/aggregate
- $25,000/$50,000/$100,000
- $75,000/$150,000/$1,000,000
- $100,000/$250,000/$1,000,000
Self-Insured Retention (SIR):*
- $1,000 (minimum)
- $1,500
- $2,500
- $5,000
- $10,000
Business Activities*
- General liability
- Owners, landlords & tenants
- Manufacturers & contractors
- Storekeepers liability
- Owner's & contractor's protective
- Contractual
- Products/Complete operations
Please list total gross receipts:*

Name:*
First Last
Mailing address:*
Street address City State Zip
E-mail:
Business telephone number:*
Fax:

Schedule of hazards:

Premises/Operations

Description	Address

Independent contractors

Description	Address

Contractual

Description	Address

Products/Completed operations

Description	Address

Other

Please describe classification	Description	Address

Does applicant draw plans, designs, or specifications:*
- Yes
- No
If "Yes", please explain:*
Do operations include blasting or storage of explosives:*
- Yes
- No
If "Yes", please explain:*
Do any operations include excavation or underground work?*
- Yes
- No
If "Yes", please explain:*
Do your subcontractors carry coverage or limits less than yours?*
- Yes
- No
If "Yes", please explain:*
Are subcontractors allowed to work without certification of insurance?*
- Yes
- No
If "Yes", please explain:*
Does applicant lease equipment to others with or without operators?*
- Yes
- No
If "Yes", please explain:*
Does Applicant install, service, or demonstrate products?*
- Yes
- No
If "Yes", please explain:*
Does Applicant conduct research and development on new products planned?*
- Yes
- No
If "Yes", please explain:*
Does Applicant use guarentees, warrenties, or hold harmless agreements?*
- Yes
- No
If "Yes", please explain:*
Does Applicant use, produce, or sell products related to aircraft/ space industry?*
- Yes
- No
If "Yes", please explain:*
Products recalled, discontued or changed?*
- Yes
- No
If "Yes", please explain:*
Does the Applicant re-package products of others under his or her label?*
- Yes
- No
If "Yes", please explain:*
Does Applicant allow products to be repackaged other the label of another?*
- Yes
- No
If "Yes", please explain:*
Is vendor's coverage required?*
- Yes
- No
If "Yes", please explain:*
Does any named insured sell to other named insureds?*
- Yes
- No
If "Yes", please explain:*
Hazards
Are any medical facilities provided or medical professionals employed or contracted?*
- Yes
- No
If "Yes", please explain:*
Any exposure to radioactive/nuclear materials?*
- Yes
- No
If "Yes", please explain:*
Any operations sold, acquired or discontinued in the last 5 years?*
- Yes
- No
If "Yes", please explain:*
Is any machinery or equipment loaned or rented to others?*
- Yes
- No
If "Yes", please explain:*
Any watercraft, docks, or floats owned, hired, or leased?*
- Yes
- No
If "Yes", please explain:*
Any parking facilities owned or rented?*
- Yes
- No
If "Yes", please explain:*
Is a fee charged for parking?*
- Yes
- No
If "Yes", please explain:*
Recreation facilities provided?*
- Yes
- No
If "Yes", please explain:*
Is there a swimming pool on the premises?*
- Yes
- No
If "Yes", please explain:*
Are there any sporting or social events sponsored?*
- Yes
- No
If "Yes", please explain:*
Any structural alterations contemplated?*
- Yes
- No
If "Yes", please explain:*
Any demolition exposure contemplated?*
- Yes
- No
If "Yes", please explain:*
Do you lease employees to or from other employers?*
- Yes
- No
If "Yes", please explain:*
Are day care facilities operated or controlled?*
- Yes
- No
If "Yes", please explain:*
Foreign products sold, distributed, used as components:*
Contractual Liability: Describe any and all hold harmless agreements (dates, contracting parties, cost) and attach a copy:
File
Max. file size: 25 MB.

Products and completed operations: Please complete the following table:*

PRODUCTS	ANNUAL GROSS SALES	NUMBER OF UNITS	TIME IN MARKET	EXPECTED LIFE	INTENDED USE	PRINCIPLE COMPONENTS

The “Applicant” is the party to be named as the "Insured" in any insuring contract if issued. By signing this Application, the Applicant for insurance hereby represents and warrants that the information provided in the Application, together with all supplemental information and documents provided in conjunction with the Application, is true, correct, inclusive of all relevant and material information necessary for the Insurer to accurately and completely assess the Application, and is not misleading in any way. The Applicant further represents that the Applicant understands and agrees as follows: (i) the Insurer can and will rely upon the Application and supplemental information provided by the Applicant, and any other relevant information, to assess the Applicant’s request for insurance coverage and to quote and potentially bind, price, and provide coverage; (ii) the Application and all supplemental information and documents provided in conjunction with the Application are warranties that will become a part of any coverage contract that may be issued; (iii) the submission of an Application or the payment of any premium does not obligate the Insurer to quote, bind, or provide insurance coverage; and (iv) in the event the Applicant has or does provide any false, misleading, or incomplete information in conjunction with the Application, any coverage provided will be deemed void from initial issuance. The Applicant hereby authorizes the Insurer and its agents to gather any additional information the Insurer deems necessary to process the Application for quoting, binding, pricing, and providing insurance coverage including, but not limited to, gathering information from federal, state, and industry regulatory authorities, insurers, creditors, customers, financial institutions, and credit rating agencies. The Insurer has no obligation to gather any information nor verify any information received from the Applicant or any other person or entity. The Applicant expressly authorizes the release of information regarding the Applicant’s losses, financial information, or any regulatory compliance issues to this Insurer in conjunction with consideration of the Application. The Applicant further represents that the Applicant understands and agrees the Insurer may: (i) present a quote with a Sub-limit of liability for certain exposures, (ii) quote certain coverages with certain activities, events, services, or waivers excluded from the quote, and (iii) offer several optional quotes for consideration by the Applicant for insurance coverage. In the event coverage is offered, such coverage will not become effective until the Insurer’s accounting office receives the required premium payment. The Applicant agrees that the Insurer and any party from whom the Insurer may request information in conjunction with the Application may treat the Applicant’s facsimile signature on the Application as an original signature for all purposes. The Applicant acknowledges that under any insuring contract issued, the following provisions will apply: 1. A single Accident, or the accumulation of more than one Accident during the Policy Period, may cause the per Accident Limit and/or the annual aggregate maximum Limit of Liability to be exhausted, at which time the Insured will have no further benefits under the Policy. 2. The Insured may request the Insurer to reinstate the original Limit of Liability for the remainder of the Policy period for an additional coverage charge, as may be calculated and offered by the Insurer. The Insurer is under no obligation to accept the Insured's request. 3. The Applicant understands and agrees that the Insurer has no obligation to notify the Insured of the possibility that the maximum Limit of Liability may be exhausted by any Accident or combination of Accidents that may occur during the Policy Period. The Insured must determine if additional coverage should be purchased. The Insurer is expressly not obligated to make a determination about additional coverage, nor advise the Insured concerning additional coverage. 4. The Insurer is herein released and relieved from any and all responsibility to notify the Insured of the possible reduction in any applicable Limit of Liability. The Insured herein assumes the sole and individual responsibility to evaluate, consider, and initiate a request for additional coverage or reinstatement of the annual aggregate Limit of Liability which may be exhausted by any single Accident or combination of Accidents during the Policy Period.
Dated:
MM slash DD slash YYYY
Applicant Name:*
First Last
By checking this box, I acknowledge that I have read and accept the terms of agreement stated above.*
- I agree
By typing my name below I represent that I have authority to enter into this agreement and that I agree to the terms and conditions stated above.*
How did you find us?*
- Blog
- Social media
- Direct mail
- Email blast / newsletter
- Referral
- Tradeshow / conference
- Internet search (Google, Bing, Yahoo, etc.)
- Trade Association
- Website (MyNewMarkets, Insurance Journal, etc.)
Please specify*

QUESTIONS?

If you have any questions, you can contact our underwriting department at 801-304-3705 or quotes@primeis.com.

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Prime Insurance Company (“PIC”) is an unlicensed excess and surplus lines insurance company domiciled in the State of Illinois and its principal place of business is in Sandy, Utah. Full disclaimer at www.primeis.com/legal.

This communication does not contain any assertion, representation, or statement with respect to the business of insurance or with respect to any person in the conduct of his or her insurance business, that is untrue, deceptive, or misleading, and that is known, or that by the exercise of reasonable care should be known, to be untrue, deceptive, or misleading.

Statements made regarding insurance coverage are for general description purposes only and they do not amend, modify, supplement, or alter any insurance policy in any way, including but not limited to claims purposes, nor do they provide details regarding terms, conditions, coverage, exclusions, or services of any insurance policy. Policy eligibility is subject to underwriting qualifications and approval. Contact PRIME INSURANCE COMPANY for more information.

All information, content, and materials available on this site are for general informational purposes only. This information does not, and is not intended to, constitute legal advice on any particular set of facts or circumstances, and may not constitute the most current legal developments. No user or browser of this site should act or refrain from acting based on the contents of this site without first seeking legal advice from counsel in the appropriate jurisdiction. This website may also contain links to content from third-party web sites which are intended only as a convenience for the user or browser and are not necessarily recommended or endorsed by Prime Holdings Insurance Services, Inc. and its affiliates. All liability with respect to actions taken or not taken based on the contents of this site are hereby expressly disclaimed. The content on this website is provided "as is" and no representations are made that the content is free of errors.

By submitting an application through this site, you acknowledge that certain personal data disclosed as part of the application process is necessary for purposes of evaluating and issuing insurance products to you by the insurer and its affiliates and you hereby consent to the insurer and its insurance affiliates processing such information. You understand that the insurer may share the information disclosed as part of the application process for purposes of evaluating and issuing insurance products and risk management services (including to the producer listed on the application), but that the insurer will not disclose your personal information to unaffiliated advertisers or vendors. You acknowledge that you have the right to withdraw your consent to the insurer's use of your personal data that is deemed by the insurer to be unnecessary for the purposes stated above by notifying us in writing.

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