Startups & High Risk Insurance - Award Winning Brokerage

General Information

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Insured Name

This is the person's name who will be listed on the insurance policy also referred to as the "First Named Insured" or Primary Account holder.

Name

This is the person's name who will be listed on the insurance policy also referred to as the "First Named Insured" or Primary Account holder.

Title

Title of the Contact Person listed above: Owner, Owner's Assistant, etc...

Phone Number

Please enter a valid phone number

Fax

Please enter a valid fax number

Email

example@example.com

Referral

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How did you hear about us?

Share your social media handle

Who referred you to us?

Referred by...

Let's be friends

Share your social media handle

Social media

Ex. @majdastouchinsurance

Business Information

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Legal Name of the Business

Business Location Address

This is the person's name who will be listed on the insurance policy also referred to as the "First Named Insured" or Primary Account holder.

Website

Enter website URL

Federal Tax ID

EIN Number

Entity Type

Corp, Sole Prop, LLC, etc.

Date business was started

This is the person's name who will be listed on the insurance policy also referred to as the "First Named Insured" or Primary Account holder.

Business Information

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Business Description

including industry type, typical services performed, clients served, products, etc.

If New Venture, list prior experience

Enter each person's cell phone number

Which State is the Business Registered in?

This is the person's name who will be listed on the insurance policy also referred to as the "First Named Insured" or Primary Account holder.

Gross Receipts Current Year

Annual sales before taxes and write offs

Gross Receipts Projection Next Year

Annual sales before taxes and write offs

Total Annual Payroll

Combine payroll of W2, 1099, Part-Time & Full-Time workers

List the job roles

List the job roles of Part Time (PT) employees...

Number of full time employees

Annual sales before taxes and write offs

% of Work Subcontracted

Annual sales before taxes and write offs

List the Number of 1099 Employees

Annual sales before taxes and write offs

Verification of insurance required prior to work start date?

Annual sales before taxes and write offs

Are you listed as an additional insured on their insurance policy?

Annual sales before taxes and write offs

Owners Payroll

Annual sales before taxes and write offs

List the number of owners

Annual sales before taxes and write offs

Do you operate any other type of business or own any other building than listed on this form?

Yes

No

Please be advised that our insurance coverage for events where alcohol is served has a limitation on coverage extending until 2:00 AM. This means that any incidents or claims arising from the event will be covered until 2:00 AM local time on the designated event date.

If Yes, please provide details:

Annual sales before taxes and write offs

Contracting Operations

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Do you have an attorney who evaluates your contracts?

Yes

No

Please be advised that our insurance coverage for events where alcohol is served has a limitation on coverage extending until 2:00 AM. This means that any incidents or claims arising from the event will be covered until 2:00 AM local time on the designated event date.

Who has the authority to sign contracts on behalf of your business?

Annual sales before taxes and write offs

Workers Compensation

Combine payroll of W2, 1099, Part-Time & Full-Time workers

Location / Building Information

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Do you own the office space?

Yes, I bought the building

No, I am a tenant occupying a space owned by someone else

Ex. I need Homeowners, Landlord, Auto...

Do you need coverage for your office?

You may need Liability, Property, or Contents coverage

Type of building you occupy

(Office, retail strip mall, industrial, etc.)

Owner or Tenant?

(Office, retail strip mall, industrial, etc.)

Square Footage of Occupied Space

Please specify the total area (in square feet) that your business occupies

Number of Stories in the Building

Indicate the total number of floors, including basements and attics, if applicable

Year of Construction

Enter the year when the building was originally constructed

Type of Construction

Frame, Masonry, Noncombustible, Fire Resistive, etc.

Percentage of Building with Sprinkler System

Estimate the percentage of your building's total area equipped with a sprinkler system

Renovations and Updates for Buildings Over 30 Years Old

- Wiring Updates: "Year when electrical systems were last updated."
- Heating System Updates: "Year when heating systems were last updated."
- Plumbing Updates: "Year when plumbing was last updated."
- Roof Updates: "Year when the roof was last updated."

Details of Alarm Systems

Specify if the alarm is for burglary, fire, or both

Would you like Business Income & Extra Expense Protection?

Specify if the alarm is for burglary, fire, or both

Business Venture

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Is this a Brand New Business Venture?

Yes

No

Please be advised that our insurance coverage for events where alcohol is served has a limitation on coverage extending until 2:00 AM. This means that any incidents or claims arising from the event will be covered until 2:00 AM local time on the designated event date.

Business Venture

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Have you had insurance coverage declined, cancelled or non-renewed during the last 3 years?

Yes

No

Please be advised that our insurance coverage for events where alcohol is served has a limitation on coverage extending until 2:00 AM. This means that any incidents or claims arising from the event will be covered until 2:00 AM local time on the designated event date.

If Yes, please provide details:

Specify if the alarm is for burglary, fire, or both

If you have been previously insured, who was the most recent insurance company?

Specify if the alarm is for burglary, fire, or both

Have you had any previous insurance claims in the last 5 years?

If Yes, please provide the details. If No, please type N/A...

Declaration Page

Please attach a copy of your most recent insurance declaration page

5 Year Loss Runs

Copies of 5 year Loss Runs for each account you have such as General Liability, Commercial Auto, Excess Liability, Cargo, Workers Compensations, Etc.

Property and General Liability

- Wiring Updates: "Year when electrical systems were last updated."
- Heating System Updates: "Year when heating systems were last updated."
- Plumbing Updates: "Year when plumbing was last updated."
- Roof Updates: "Year when the roof was last updated."

Automobile

- Wiring Updates: "Year when electrical systems were last updated."
- Heating System Updates: "Year when heating systems were last updated."
- Plumbing Updates: "Year when plumbing was last updated."
- Roof Updates: "Year when the roof was last updated."

Workers Compensation

- Wiring Updates: "Year when electrical systems were last updated."
- Heating System Updates: "Year when heating systems were last updated."
- Plumbing Updates: "Year when plumbing was last updated."
- Roof Updates: "Year when the roof was last updated."

Umbrella

- Wiring Updates: "Year when electrical systems were last updated."
- Heating System Updates: "Year when heating systems were last updated."
- Plumbing Updates: "Year when plumbing was last updated."
- Roof Updates: "Year when the roof was last updated."

Cyber Liability

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Do you want Cyber Liability?

Yes

No

Please be advised that our insurance coverage for events where alcohol is served has a limitation on coverage extending until 2:00 AM. This means that any incidents or claims arising from the event will be covered until 2:00 AM local time on the designated event date.

Cyber Liability

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Do you, or an outsourced firm, back up your data and systems at least once a week, and store these backups in an off-site location?

Yes

No

Please be advised that our insurance coverage for events where alcohol is served has a limitation on coverage extending until 2:00 AM. This means that any incidents or claims arising from the event will be covered until 2:00 AM local time on the designated event date.

Do you have anti-virus software and firewalls in place and that are regularly updated (at least quarterly)?

Yes

No

Please be advised that our insurance coverage for events where alcohol is served has a limitation on coverage extending until 2:00 AM. This means that any incidents or claims arising from the event will be covered until 2:00 AM local time on the designated event date.

After inquiry of the “Control Group”, as defined, are you aware of any or have any grounds for suspecting any circumstances which might give rise to a claim?

Yes

No

Please be advised that our insurance coverage for events where alcohol is served has a limitation on coverage extending until 2:00 AM. This means that any incidents or claims arising from the event will be covered until 2:00 AM local time on the designated event date.

Within the last 5 years, has “your Organization” suffered any system intrusions, tampering, virus or malicious code attacks, loss of data, loss of portable media, hacking incidents, extortion attempts, or data theft, resulting in a claim in excess of $25,000 that would be covered by this insurance?

Yes

No

Please be advised that our insurance coverage for events where alcohol is served has a limitation on coverage extending until 2:00 AM. This means that any incidents or claims arising from the event will be covered until 2:00 AM local time on the designated event date.

Property Insurance

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Do you want Property Insurance?

Yes

No

Please be advised that our insurance coverage for events where alcohol is served has a limitation on coverage extending until 2:00 AM. This means that any incidents or claims arising from the event will be covered until 2:00 AM local time on the designated event date.

Property Insurance

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Building Description

Provide a brief description of the building, including its primary use and any unique features

Value of Business Contents for Replacement

Estimate the total value needed to replace all contents within your business premises

Improvements and Betterments to Building

Detail any enhancements or upgrades made to the building that increase its value

Value of Computers

Specify the total value of all computers used in your business

Computer Software Value

Estimate the value of the computer software essential to your business operations

Property Used or Stored Off Premises

List any business property that is regularly used or stored at locations other than your main business premises

Accounts Receivable Value

Indicate the total value of outstanding accounts receivable for your business

Exterior Signage

Do you have any exterior signs associated with your business? If yes, please describe

Value of Miscellaneous Mobile Tools and Equipment

Estimate the total value of mobile tools and equipment used in your business

List of Scheduled Mobile Equipment

Provide a detailed list of mobile equipment (e.g., vehicles, machinery) that requires specific coverage

Attach Schedule

Copies of 5 year Loss Runs for each account you have such as General Liability, Commercial Auto, Excess Liability, Cargo, Workers Compensations, Etc.

Do you rent or loan equipment to others?

Yes

No

Please be advised that our insurance coverage for events where alcohol is served has a limitation on coverage extending until 2:00 AM. This means that any incidents or claims arising from the event will be covered until 2:00 AM local time on the designated event date.

If Yes, please provide details:

Specify if the alarm is for burglary, fire, or both

Contents may include, but is not limited to: Leasehold Improvements, Leased Property, Inventory, Furniture/Fixtures, Equipment, Printed Materials, Consumables, and Property of Others in Your Care. Please consult your lease requirements when choosing the coverage and limits for this location.

Crime Insurance

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Do you want Crime Insurance?

Yes

No

Please be advised that our insurance coverage for events where alcohol is served has a limitation on coverage extending until 2:00 AM. This means that any incidents or claims arising from the event will be covered until 2:00 AM local time on the designated event date.

Crime Insurance

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Employee Dishonesty Coverage Limit

Specify the maximum coverage amount for claims related to employee dishonesty

Do you have a 401(k) plan for your employees?

If yes, please provide the name of the 401(k) plan

Forgery or Alteration Coverage Limit

Indicate the maximum coverage amount for claims involving forgery or alteration of financial instruments

Theft of Money Coverage (Inside/Outside Premises)

Specify coverage limits for theft of money both within and outside the business premises

Computer Fraud Coverage Limit

Determine the maximum coverage amount for claims related to computer fraud

Each Occurrence Limit

State the coverage limit per individual incident or occurrence

General Aggregate Coverage Limit

Specify the total coverage limit for all claims during the policy period

Fire Legal Liability Coverage Limit

Indicate the maximum amount covered for fire damage for which your business is legally responsible

Medical Payments Coverage Limit

Define the limit for medical payments coverage, typically used for minor injuries to non-employees

Do you require subcontractors to have insurance, and do you obtain Certificates of Insurance?

Yes

No

Please be advised that our insurance coverage for events where alcohol is served has a limitation on coverage extending until 2:00 AM. This means that any incidents or claims arising from the event will be covered until 2:00 AM local time on the designated event date.

PROPERTY | CRIME | GENERAL LIABILITY SECTION COMMENTS:

Define the limit for medical payments coverage, typically used for minor injuries to non-employees

Workers Compensation

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Do you want Workers Compensation Insurance?

Yes

No

Please be advised that our insurance coverage for events where alcohol is served has a limitation on coverage extending until 2:00 AM. This means that any incidents or claims arising from the event will be covered until 2:00 AM local time on the designated event date.

Workers Compensation

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Please provide detailed information for each owner and officer, including their full names, titles, ownership percentages, roles within the company, and their annual payroll figures. This will enable us to assess your needs accurately and tailor your workers' compensation coverage effectively.

Owner/Officer's Full Name

Enter the full legal name of the owner or officer

Position Title

Specify the official title or position held within the company

Ownership Percentage

Indicate the percentage of the company's ownership held by this individual

Role and Duties

Describe the primary duties and responsibilities of this owner/officer. If inactive in daily operations, please state 'Inactive'

Annual Payroll

Provide the annual payroll amount for this owner/officer, if applicable

Include or Exclude this Owner/Officer from Workers' Compensation Coverage?

Indicate whether to include or exclude this individual from workers' compensation insurance coverage

Delete

Add Owner

Business Auto Insurance

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Are you interested in Business Auto Insurance?

Yes

No

Please be advised that our insurance coverage for events where alcohol is served has a limitation on coverage extending until 2:00 AM. This means that any incidents or claims arising from the event will be covered until 2:00 AM local time on the designated event date.

Business Auto Insurance

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Upload Vehicle Schedule

Please upload a comprehensive list of all vehicles used for business purposes. This schedule should include details such as make, model, year, vehicle identification number (VIN), and usage type for each vehicle. Ensure the document is current and includes all vehicles that require coverage under the business auto insurance policy.

Upload Driver Schedule

Please upload a complete list of all drivers who operate the business vehicles. This schedule should contain full names, driving license numbers, dates of birth, and driving histories for each driver. Include any relevant certifications or training completed by the drivers. This information is vital for assessing risk and determining the appropriate insurance coverage.

Automobile Liability Coverage

Specify the limits and scope of liability coverage for your business vehicles

Uninsured/Underinsured Motorist Coverage Limits

Indicate the coverage limits for incidents involving uninsured or underinsured motorists

Medical Payments Coverage

Specify the limit of medical payments coverage for injuries sustained in a vehicular accident

Personal Injury Protection (PIP) Coverage

Detail the coverage limit for Personal Injury Protection, including medical expenses and lost wages

Comprehensive Coverage Deductible

State the deductible amount for comprehensive coverage (non-collision events)

Collision Coverage Deductible

Indicate the deductible amount for collision coverage

Towing and Labor Coverage

Specify if towing and labor costs are covered and to what extent

Rental Reimbursement Coverage

Detail the coverage for rental vehicle costs in case of your business vehicle's unavailability

Do you rent vehicles for business purposes?

Indicate if your business rents vehicles for any operational needs

Number of Days Vehicles are Rented Annually

If you rent vehicles for business use, specify the approximate number of days per year

Do employees use personal vehicles for business?

Yes

No

Please be advised that our insurance coverage for events where alcohol is served has a limitation on coverage extending until 2:00 AM. This means that any incidents or claims arising from the event will be covered until 2:00 AM local time on the designated event date.

If Yes, please provide details:

Specify if the alarm is for burglary, fire, or both

Auto section comments

If you rent vehicles for business use, specify the approximate number of days per year

Final

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My insurance renewal is in:

I agree to terms of engagement

Ex. I need Homeowners, Landlord, Auto...

Acknowledged and agreed by client:

Save

Clear

You are not required to pay for services or utilize our office to secure insurance services in exchange for obtaining your insurance policy. While you have chosen to collaborate with Majdas Touch Insurance, Inc., you are under no obligation to do so, and you retain the freedom to explore other brokerages without incurring any fees. The decision to continue paying this fee is entirely voluntary, and you are making it of your own accord and volition.

Majdas Touch

Navigating Risks, Cultivating Success

Navigate the Unknown with Confidence

A Deeper Dive Into Our Offerings

Product Liability

Cyber Liability

Professional Liability

Commercial Property

Pioneers Welcome

@majdastouchinsurance