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What We Do
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Insurance Solutions
Forms & Resources
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Contact

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Forms & Resources

Business Owner's Insurance

Please complete all required fields!

By providing the following information Hidden Valley Insurance will provide you with competitive quotes from multiple insurance carriers. There is no obligation to purchase.

General Business Information

Name of Insured (include all entities, subsidiaries, and DBAs to be included as named insured)*

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Firm Type*

Firm Type

Corp

Partnership

LLC/LLP

Sole Proprietorship

Joint Venture

Other

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Mailing Address*

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City*

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State*

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Zip Code*

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Principal Contact*

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Title*

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Email*

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Phone*

Please input in valid format (123-456-7890)

Fax

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Year Business Started*

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If you have been in business fewer than 3 years, please attach resumes of key personnel.

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Federal Tax # (FEIN)*

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Current Insurance Carrier*

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Have you had any losses or claims in the last 3 years?

Yes

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If yes, please provide 3 loss runs (a statement of actual loss history provided by your insurance carrier) or attach a description of the claim, including date, loss type, and loss amount. We can assist in obtaining your loss run report.

Please attach a Loss Runs Report

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Do you need assistance with loss runs?

Yes

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Description of operations*

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Do you have any foreign operations?

Yes

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{if If yes, please explain.}

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For manufacturers only: Do you incorporate foreign products in the manufacturing process?

Yes

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Number of owners*

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Number of Employees*

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Gross annual revenue*

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Annual payroll*

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Desired effective date of coverage (DD/MM/YYYY)*

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Location Information

Address of property to be insured (Note: Please complete one form per location)

Address*

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City*

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State*

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Zip Code*

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County*

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Construction Type

Frame

Masonry

Other

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Construction Type Description*

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Type of Occupancy*

Type of Occupancy

Tenant

Owner Occupied

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Year Built*

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If year built is greater than 30 years, provide the year of most recent updates.

Electrical

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Plumbing

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Roof

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Heating

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Construction & Building Details

Does the building have a functioning sprinkler system?*

Does the building have a functioning sprinkler system?

Yes

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{if If yes, percent sprinklered}

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Total square footage of the building your business is in*

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Number of Stories*

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Total square footage you occupy*

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Approximate feet to the nearest fire hydrant? *

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Approximate miles to the nearest fire department?*

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Theft alarm*

Theft alarm

Local

Monitored

None

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Fire alarm*

Fire alarm

Local

Monitored

None

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Keyed Entry*

Keyed Entry

Yes

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Building limit requested if insuring the building

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Business contents limit

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Building Contents Deductible

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Computer Hardware Equipment Limit

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Computer Software Equipment Limit

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If coverage is desired for property that is not always at your location address, please provide an equipment list that includes: description of item, value, serial number, and model.

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Or Upload Document with Equipment List

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Coverage and Liability Limits

General Liability Limit

$1 Mil/$2 Mil

Other

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{if If other, please specify}

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Cyber Liability

Yes

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Cyber Liability Requested Limit

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Professional Liability

Yes

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Professional Liability Requested Limit

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Crime/Fiduciary/ERISA

Yes

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Crime/Fiduciary/ERISA Requested Limit

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Employee Benefits Liability

Yes

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Employee Benefits Retro Date

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Employment Practices Liability

Yes

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Employment Practices Requested Limit

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Directors & Officers Insurance

Yes

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Directors & Officers Insurance Requested Limit

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Are there any vehicles owned by the named insured?

Yes

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If yes, a separate application is required. Indicate if you need the application.

Yes, please send.

No, thank you.

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Non-Owned/ Hired Auto Liability

Yes

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Hired Auto Physical Damage

Yes

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Hired and non-Owned Auto Questions

Annual cost of hire/rental of autos (if any)

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Number of employees that drive their own cars for company business on a regular basis

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Do you check each driver's motor vehicle record prior to hire and/or annually thereafter?

Yes

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Do you have a procedure for verifying employees' personal auto insurance?

Yes

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Do you require minimum limits of liability on employees' personal insurance?

Yes

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{if If Yes, what limit?}

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Tell us any additional information that you would like to include.

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Please note that we may request additional information to determine liability and obtain appropriate quotes. If Flood or Earthquake quotes are needed, please contact our office.

By submitting this request, you authorize us to research options based on your answers.

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