Commercial New Business Information Sheet

Producer Name Proposed Effective Date

Applicant Named Bank Referred ☐ Yes ☐ No

Insured Referral Name
Mailing Address: Phone
Fax
Email
Website
Contact Name Contact Role Contact Cell Contact Email ☐Claims ☐Risk
Control
☐Claims ☐Risk
Control
☐Claims ☐Risk
Control

Current Program:
GENERAL LIABILITY AUTOMOBILE PROPERTY

CARRIER
POLICY NUMBER
PREMIUM
WHOLESALE/ADMITTED
EFFECTIVE DATE
EXPIRATION DATE

Company Info:
Will the agency charge any Service ☐Yes ☐ No Legal Entity Type: ☐ LLC ☐ Sub S Corp ☐ Non-Profit ☐
Fees to the Client?
Partnership

FEIN #: Yr. Business

Started:
Annual Sales: PCRB File No.
Domestic Sales: NCCI File No.
Foreign Sales: # of FULL
Employees:

1 Commercial New Business Information Sheet

 # OF PART TIME
EMPLOYEES
Loss Runs? ☐Yes ☐ No SIC Code
NAICS Code
Operations Description:

Property:
LOC: BLDG: Physical STREET
Address:
CITY
STATE
COUNTY
ZIP
Description:
Blanket? YES NO ☐ BLDG ☐ BPP ☐ BLDG & BPP
BLDG Limit BPP BUS INC & EE Limit Coins % Valuation Cause of Deductible Other
Limit Loss

COPE Info:
Construction Prot Class # of Stories Year Total Updates
Type Built Area Wiring Roof Plumbing HVAC

Endorsements

Additional
Interests

Property:
LOC: BLDG: Physical Address:
Description:
Blanket? YES NO ☐ BLDG ☐ BPP ☐ BLDG & BPP
BLDG Limit BPP BUS INC & EE Limit Coins % Valuation Cause of Deductible Other
Limit Loss

COPE Info:
Construction Prot Class # of Year Built Total Area Updates
Type Stories Wiring Roof Plumbing HVAC

2 Commercial New Business Information Sheet

Endorsements

Additional
Interests

Property:
LOC: BLDG: Physical STREET
Address:
CITY
STATE
COUNTY
ZIP
Description:
Blanket? YES NO ☐ BLDG ☐ BPP ☐ BLDG & BPP
BLDG Limit BPP BUS INC & EE Limit Coins % Valuation Cause of Deductible Other
Limit Loss

COPE Info:
Construction Prot Class # of Stories Year Total Updates
Type Built Area Wiring Roof Plumbing HVAC

Endorsements

Additional
Interests

3 Commercial New Business Information Sheet

 Crime:

Inland Marine:
Territory of Operations:
Type of Operations:
Coverage:

Schedule of Equipment:
Item # Year Manufacturer Model | ID No. | Serial Amount Other
Description #

4 Commercial New Business Information Sheet

General Liability:
General Aggregate:
Products & Completed Operations:
Personal & Advertising Injury:
Limits Each Occurrence:
Damage to Rented Premises:
Medical Expense:
Employee Benefits:
Claims Made or
Occurrence
Classifications:

Endorsements
Waiver of Subro: Yes No
Additional Interests

Additional Coverages &

Remarks

5 Commercial New Business Information Sheet

Business Auto:
Liability (CSL)
PIP
Work Loss Benefit:
Added PIP Funeral Benefit:
Accidental Death:
Med Pay
UM ☐ Stacked ☐ Unstacked
Limits
UIM ☐ Stacked ☐ Unstacked
Comprehensive Ded.
Collision Ded.
Towing & Labor ☐Yes ☐ No Limit
Hired Auto
Non-Owned Auto
Hired Auto | Non-Owned Auto Physical Damage Comp Ded Coll Ded
Vehicle Schedule:
Veh # Year Make Model Vin # Cost New COLL/DED

Driver Schedule:
Driver # Driver Name DOB DL # DL State Other

Endorsements

6 Commercial New Business Information Sheet

Workers Compensation:
Current Market LCM: Eff Date:
PCRB | NCCI File No.
Experience Mod. Policy Period Mod

Safety Credit ☐Yes ☐ No

Classifications:

7 Commercial New Business Information Sheet

Additional Coverages:
Professional Liability ☐

D&O ☐

EPLI ☐

Abuse & Molestation ☐

Cyber ☐

Flood ☐

Bonds ☐

Benefits ☐

Personal Lines ☐

8 Commercial New Business Information Sheet

Notes | Miscellaneous:
Need by date
Proposal
Referral Name:

Referral Office:

Annual Premium

Risk Narrative: What can we share with the markets to sell this account? Please do not copy and paste Website Info

Loss Runs: ☐ Yes ☐ No

☐ Producer Has Had Loss Run Discussion with Prospect
☐ Prospect Has Ordered Loss Runs from Incumbent Agent
Do we need to
approach markets
without formal
submission?
“Email Feeler” If
so list desired
markets.
Enthusiasm for ☐ Green Access to Decision ☐ Green Relationship to ☐ Green
☐ Yellow ☐ Yellow ☐ Yellow
Our Process Maker Current Broker
☐ Red ☐ Red ☐ Red
Opportunity for Opportunity for EB Opportunity for
Personal Lines Cross Sell FNB Corp Cross Sell
Cross Sell

9 Commercial New Business Information Sheet