Hidden Valley Insurance | Utah and Nationwide Insurance Brokers

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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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?

YesNo Invalid Input

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?

YesNo Invalid Input

Description of operations*

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Do you have any foreign operations?

YesNo Invalid Input

If yes, please explain.

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

YesNoNA Invalid Input

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

FrameMasonryOther Invalid Input

Construction Type Description*

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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

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

Are there any vehicles owned by the named insured?

YesNo Invalid Input

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

Yes, please send.No, thank you. Invalid Input

Non-Owned/ Hired Auto Liability

YesNo Invalid Input

Hired Auto Physical Damage

YesNo Invalid Input

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?

YesNo Invalid Input

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

YesNo Invalid Input

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

YesNo Invalid Input

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.

Business Owner's Insurance

General Business Information

Location Information

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

Construction & Building Details

Coverage and Liability Limits

Hired and non-Owned Auto Questions