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Quote Property?
- Yes
- No
Quote EPL?
- Yes
- No
COMMON INFO
Applicant Information
Name of Entity (if any)
Type of Business
- (individual)
- Inc
- Corp
- Ltd
- LLC
- PC
- Partnership
DBA Name (if any)
Owner Name
First Last
Where do you most often work?

PROPERTY SECTION
SELECT THE LINES OF BUSINESS TO QUOTE
- Property
- Commercial General Liability
Quote Term
Year Business Started
Years at Current Location
Any losses/claims in past three years?
Is USLI the expiring carrier?
Description of Operations
Beauty/Barber/Nail Classification Selection
Please classify the applicant
Number of full-time operators (20+ hours per week)
Number of part-time operators (under 20 hours per week)
Address Information
Mailing Address
Street Address Address Line 2 City State ZIP Code
Total Number Locations
Count locations where you regularly work (at least once per week).
What is your primary LOCATION address?
If you work from more than one location, provide information regarding your main location.

Street Address City State ZIP Code
List all other location addresses
Include locations where you regularly work (at least once per week).
Property
Describe building construction type (reasonable guess is OK)*
- Frame (wood frame, often looks like a "house")
- Joisted Masonry (normally brick outside with wood inside)
- Concrete Tilt-Up (like a big warehouse store)
- Fire Resistive (brand new fireproof building like a hotel or hospital)
- Other/Not Sure (please describe)
Protection Class
Requested Cause of Loss
Requested Valuation
Requested Deductible
Co-Insurance
Estimated Year Built*
Type of Plumbing
Type of Roof
Estimated Year Roof Installed*
Is the building protected by an operational sprinkler system covering 100% of the premises?*
If not sure, answer "no".
- Yes
- No
Do you own the building?*
- Yes
- No
Estimated replacement value of your building*
What would it cost to completely rebuild the structure? Minimum available coverage amount is $10,000.
Please enter a number from 10000 to 10000000.
Estimated replacement value of your contents*
"Property" coverage applies the physical loss or damage to your tools, equipment, furnishings, and inventory--everything in the business that you own, or that was installed at your expense. What would it cost to buy everything again? Minimum available coverage amount is $5,000.
Please enter a number from 5000 to 5000000.
What type of Burglar Alarm is on premises?*
- Central Station Monitored
- Local
- None
Does the applicant engage in any operations or have any classifications other than those determined so far?
Property Coverages
ADD EQUIPMENT BREAKDOWN?
ADD THE VALUE ENDORSEMENT?
ADD ELECTRONIC DATA COVERAGE?
ADD INTERRUPTION OF COMPUTER OPERATIONS COVERAGE?
ADD ACCOUNTS RECEIVABLE COVERAGE?
ADD BUSINESS INCOME WITH EXTRA EXPENSE COVERAGE?
Estimated Annual Sales*
Total annual sales before paying any bills. This will help us to provide the correct amount of business interruption coverage.
COINSURANCE
ADD EXTRA EXPENSE COVERAGE?
ADD CANOPY/AWNING COVERAGE?
Add glass coverage?*
- Yes
- No
Linear Feet*
How many feet across? (Total of all windows)
GLASS DEDUCTIBLE
ADD IMPROVEMENTS OR BETTERMENTS COVERAGE?
ADD OUTDOOR SIGN COVERAGE?
ADD VALUABLE PAPERS COVERAGE?
Property Applicant Eligibility
Are there past, pending, or planned foreclosures and/or bankruptcies or judgments for unpaid taxes against the name insured or any officer, partner, member or owner, individually within the last five years?
Has insurance coverage been cancelled or non-renewed in the past three years? (not applicable in MO)
Has insurance coverage been cancelled or non-renewed in the past three years? (not applicable in MO)
Property Location Eligibility
Do all public areas, occupancies and/or habitational units have functioning and operational smoke and/or heat detectors?

EMPLOYMENT PRACTICES LIABILITY SECTION
Applicant Information
Within the last five years, has any employment related, or third party discrimination, or third party harassment inquiry, complaint, notice of hearing, claim or suit been made against any entity proposed for insurance or any person proposed for insurance in the capacity of either director, officer, member (if an LLC), or employee of any entity proposed for insurance?
Has the applicant, any subsidiary, or any entity seeking coverage, ever had a policy with United States Liability Insurance Co., Mt. Vernon Fire Insurance Co., U.S. Underwriters Co. or Mt. Vernon Specialty Insurance Co.?
Do you have a business website?*
- Yes
- No
Business website address*
Description of Operations
Address Information
Mailing Address
Street Address Address Line 2 City State ZIP Code
Total Number Locations
Count locations where you regularly work (at least once per week).
What is your primary LOCATION address?
If you work from more than one location, provide information regarding your main location.

Same as mailing

Street Address City State ZIP Code
List all other location addresses
Include locations where you regularly work (at least once per week).
Employment Practices Liability
Does the organization currently carry Employment Practices Liability Coverage?
Please select Retro Inception or Full Prior Acts. If Full Prior Acts is selected, premium will increase.
How many full-time employees?
How many part-time employees?
How many temporary/seasonal employees?
How many independent contractor employees?
How many leased employees?
Are there employees/independent contractors in California, Florida, Louisiana or outside the U.S.?*
- Yes
- No
Is any person(s) proposed for this Insurance aware of any fact, circumstance or situation which may result in an employment claim, or third party discrimination, or third party harassment claim against any entity proposed for Insurance or any of its Directors, Officers, Members (if an LLC), or Employees?
Would you like to purchase Third Party Employment Practices Liability Coverage?
Do more than 50% of all employees currently earn more than $100,000?*
- Yes
- No
Is the applicant a Subsidiary of another organization?
Is the applicant a Franchisee of another organization?
Does the Applicant want any Subsidiary(s)/Affiliate(s) covered?
Has any entity proposed for Insurance closed, sold, merged with or acquired any company in the past 12 months or anticipates doing so in the next 12 months?
Has any entity proposed for Insurance downsized, laid off, or reduced staff in the past 12 months or anticipates doing so in the next 12 months?
Has any policy for Employment Practices Liability ever been cancelled or non-renewed? (Not applicable in MO)
Does each entity proposed for insurance have a written Anti-Discrimination Policy currently in place?
Does each entity proposed for insurance have a written Anti-Harassment Policy currently in place?
Does each entity proposed for Insurance have a written Email/Internet Policy currently in place?
WC1
WC2

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