Nucleus Insurance - Business Commericial Quote

General Information

1a. Is The Applicant A Subsidiary Of Another Entity ?

Yes

No

1b. Does The Applicant Have Any Subsidiaries?

Yes

No

2. Is A Formal Safety Program In Operation?

Yes

No

Select

3. Any Exposure To Flammables, Explosives, Chemicals?

Yes

No

Describe

4. Any Other Insurance With This Company? (list Policy Numbers)

Yes

No

5. Any Policy Or Coverage Declined, Cancelled Or Non-renewed During The Prior Three (3) Years For Any Premises Or Operations? (Missouri Applicants - Do not answer this question)

Yes

No

Select

Describe

6. Any Past Losses Or Claims Relating To Sexual Abuse Or Molestation Allegations, Discrimination Or Negligent Hiring?

Yes

No

Describe

7. During The Last Five Years (ten In Ri), Has Any Applicant Been Indicted For Or Convicted Of Any Degree Of The Crime Of Fraud, Bribery, Arson Or Any Other Arson-related Crime In Connection With This Or Any Other Property? (In RI, this question must be answered by any applicant for property insurance. Failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one year of imprisonment)

Yes

No

Describe

8. Any Uncorrected Fire And/or Safety Code Violations?

Yes

No

9. Has Applicant Had A Foreclosure, Repossession, Bankruptcy Or Filed For Bankruptcy During The Last Five (5) Years?

Yes

No

10. Has Applicant Had A Judgement Or Lien During The Last Five (5) Years?

Yes

No

11. Has Business Been Placed In A Trust?

Yes

No

12. Any Foreign Operations, Foreign Products Distributed In Usa, Or Us Products Sold / Distributed In Foreign Countries?

Yes

No

13. Does Applicant Have Other Business Ventures For Which Coverage Is Not Requested?

Yes

No

Describe

14. Does Applicant Own / Lease / Operate Any Drones?

Yes

No

Describe

15. Does Applicant Hire Others To Operate Drones? (if "yes", Describe Use)

Yes

No

Describe

Existing Policy Information

Currently Insured

Yes

No

Type of Category

Loss History

Loss history(do you have losses? If yes how many losses since the beginning of the business, thats it)

Yes

No

Products/Completed Operations

1. Does Applicant Install, Service Or Demonstrate Products?

Yes

No

2. Foreign Products Sold, Distributed, Used As Components?

Yes

No

3. Research And Development Conducted Or New Products Planned?

Yes

No

4. Guarantees, Warranties, Hold Harmless Agreements?

Yes

No

5. Products Related To Aircraft/space Industry?

Yes

No

6. Products Recalled, Discontinued, Changed?

Yes

No

7. Products Of Others Sold Or Re-packaged Under Applicant Label?

Yes

No

8. Products Under Label Of Others?

Yes

No

9. Vendors Coverage Required?

Yes

No

10. Does Any Named Insured Sell To Other Named Insureds?

Yes

No

Location/Office Information

City

State

Interest

Description Of Operations

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Commercial General Information

1. Any Medical Facilities Provided Or Medical Professionals Employed Or Contracted?

Yes

No

2. Any Exposure To Radioactive/Nuclear Materials?

Yes

No

3. Do/have Past, Present Or Discontinued Operations Involve(d) Storing, Treating, Discharging, Applying, Disposing, Or Transporting Of Hazardous Material? (e.g. Landfills, Wastes, Fuel Tanks, Etc)

Yes

No

4. Any Operations Sold, Acquired, Or Discontinued In Last Five (5) Years?

Yes

No

5. Do You Rent Or Loan Equipment To Others?

Yes

No

Type Of Equipment

Instruction Given

Type Of Equipment (Optional)

Instruction Given (Optional)

6. Any Watercraft, Docks, Floats Owned, Hired Or Leased?

Yes

No

7. Any Parking Facilities Owned/rented?

Yes

No

8. Is A Fee Charged For Parking?

Yes

No

9. Recreation Facilities Provided?

Yes

No

10. Are There Any Lodging Operations Including Apartments?

Yes

No

11. Is There A Swimming Pool On Premises? (Check all that apply)

Yes

No

Approved Fence

Limited Access

Diving Board

Slide

Above Ground

In Ground

Life Guard

12. Are Social Events Sponsored?

Yes

No

13. Are Athletic Teams Sponsored?

Yes

No

Contact Sport

Age Group

Contact Sport (Optional)

Age Group (Optional)

14. Any Structural Alterations Contemplated?

Yes

No

15. Any Demolition Exposure Contemplated?

Yes

No

16. Has Applicant Been Active In Or Is Currently Active In Joint Ventures?

Yes

No

17. Do You Lease Employees To Or From Other Employers?

Yes

No

Workers Compensation Coverage Carried

18. Is There A Labor Interchange With Any Other Business Or Subsidiaries?

Yes

No

19. Are Day Care Facilities Operated Or Controlled?

Yes

No

20. Have Any Crimes Occurred Or Been Attempted On Your Premises Within The Last Three (3) Years?

Yes

No

21. Is There A Formal, Written Safety And Security Policy In Effect?

Yes

No

22. Does The Businesses' Promotional Literature Make Any Representations About The Safety Or Security Of The Premises?

Yes

No

Coverage Details

What coverage are you looking for?

Liability

Full Coverage

Coverage Details

BASIC

Liability Only

Liability

$15,000

$30,000

$10,000

per damage

Comprehensive

$1,000

Collision

$1,000

STANDARD

Liability with Uninsured Motorist

$15,000

$30,000

$10,000

per damage

Uninsured Motorist

$15,000

$30,000

Collision Deductible Waiver

CDW

Uninsured Motorist Property Damage

$3,500

Comprehensive

$1,000

Collision

$1,000

PREMIUM

Liability with Uninsured Motorist

$25,000

$50,000

$10,000

Liability with Uninsured Motorist

$15,000

$30,000

$10,000

Uninsured Motorist

$25,000

$50,000

Uninsured Motorist

$15,000

$30,000

Collision Deductible Waiver

CDW

Uninsured Motorist Property Damage

$10,000

Comprehensive

$500

Collision

$500

Workers Compensation General Information

1. Does Applicant Own, Operate Or Lease Aircraft / Watercraft?

Yes

No

2. Do / Have Past, Present Or Discontinued Operations Involve(d) Storing, Treating, Discharging, Applying, Disposing, Or Transporting Of Hazardous Material? (e.g. Landfills, Wastes, Fuel Tanks, Etc)

Yes

No

3. Any Work Performed Underground Or Above 15 Feet?

Yes

No

4. Any Work Performed On Barges, Vessels, Docks, Bridge Over Water?

Yes

No

5. Is Applicant Engaged In Any Other Type Of Business?

Yes

No

6. Are Sub-contractors Used? (if "yes", Give % Of Work Subcontracted)

Yes

No

7. Any Work Sublet Without Certificates Of Insurance? (if "yes", Payroll For This Work Must Be Included In The State Rating Worksheet On Page 2)

Yes

No

8. Is A Written Safety Program In Operation?

Yes

No

9. Any Group Transportation Provided?

Yes

No

10. Any Employees Under 16 Or Over 60 Years Of Age?

Yes

No

11. Any Seasonal Employees?

Yes

No

12. Is There Any Volunteer Or Donated Labor? (if "yes", Please Specify)

Yes

No

13. Any Employees With Physical Handicaps?

Yes

No

14. Do Employees Travel Out Of State? (if "yes", Indicate State(s) Of Travel And Frequency)

Yes

No

15. Are Athletic Teams Sponsored?

Yes

No

16. Are Physicals Required After Offers Of Employment Are Made?

Yes

No

17. Any Other Insurance With This Insurer?

Yes

No

18. Any Prior Coverage Declined / Cancelled / Non-renewed In The Last Three (3) Years? (missouri Applicants - Do Not Answer This Question)

Yes

No

19. Are Employee Health Plans Provided?

Yes

No

20. Do Any Employees Perform Work For Other Businesses Or Subsidiaries?

Yes

No

21. Do You Lease Employees To Or From Other Employers?

Yes

No

22. Do Any Employees Predominantly Work At Home?

Yes

No

23. Any Tax Liens Or Bankruptcy Within The Last Five (5) Years?

Yes

No

24. Any Undisputed And Unpaid Workers Compensation Premium Due From You Or Any Commonly Managed Or Owned Enterprises?

Yes

No

Supplemental Information

1. Has There Been Previous Workers Compensation Coverage

Yes

No

In This State?

Yes

No

In Any Other State?

Yes

No

If No To Both Questions, Was This Due To

2. Is There Any Unpaid Workers Compensation Premium Due Or In Dispute From You Or Any Commonly Managed Or Owned Enterprises?

Yes

No

3. Year Applicant's Business Began

Yes

No

4. Has There Been A Name Change, Consolidation, Merger, Acquisition, Sale, Purchase Or Transfer Of Assets Or ClaOwnership Change During The Past Five (5) Years?

Yes

No

5. Is Applicant Related Through Common Management Or Ownership To Any Entity Not Listed On The Acord 130 Form, Whether Coverage Is Required Or Not?

Yes

No

6. Do You Lease Workers From A Professional Employer Organization (PEO)?

Yes

No

7. Do You Lease Workers To A Client Company?

Yes

No

8. To Cover The Leased Workers?

Yes

No

9. Do You Provide Temporary Arrangement Services To Other Employers?

Yes

No

10. Do You Have A Franchise Or Licensing Agreement?

Yes

No

11. Is Coverage Requested For A Sports Team?

Yes

No

12. Do Trucking Classifications Apply? If Yes, Complete Questions 13 - 20.

Yes

No

13. Do You Or Your Employees Regularly Operate From A Base Terminal(s) Which Is (are) Used To Load, Unload, Store Or Transfer Freight?

Yes

No

14. Can Each Driver's State Of Majority Driving Time Be Established Through Verifiable Records Or Logs?

Yes

No

15. Please Provide A List Of All Drivers / Helpers And Their State Of Residence

Yes

No

16. What Type(s) Of Goods Are Being Hauled? (e.g., Coal, Dry Goods, Explosives, Scaffolding, Water / Waste Fluids From Oil Field Sites, Etc.)

Yes

No

17. Do You Own These Goods?

Yes

No

18. Is Applicant Under Exclusive Contract With Any Retail Store(s)?

Yes

No

19. Is Applicant Under Exclusive Contract With Any Postal Service?

Yes

No

20. Within What Mile Radius Is Hauling Done?

Yes

No

21. Have You Received Any Offers Of Voluntary Coverage?

Yes

No

22. Indicate The Number Of Insurance Companies Which Have Refused The Applicant Coverage In The Last 60 Days (or In Accordance With State Specific Guidelines)

Yes

No

23. Is The Premium Financed Through A Third Party Premium Finance Company? If Yes, A Copy Of The Agreement Must Be Provided.

Yes

No

24. In Applicable Jurisdictions On Qualifying Risks, Is The Loss Sensitive Rating Program (LSRP) Contingency Deposit Being Paid In Full At This Time?

Yes

No

Thank you for filling out your information

Our team will contact you soon.

If you have any query or concern, please contact us without any hesitate

Business Owners Information

1. Do/have Past, Present Or Discontinued Operations Involve(d) Storing, Treating, Discharging, Applying, Disposing, Or Transporting Of Hazardous Material? (e.g. Landfills, Wastes, Fuel Tanks, Etc)

Yes

No

2. Are Athletic Teams Sponsored?

Yes

No

3. Are Sub Contractors Allowed To Work Without Providing A Certificate Of Insurance? If Not, Who Checks Certificates?

Yes

No

4. During The Last Five Years (ten In Ri), Has Any Applicant Been Indicted For Or Convicted Of Any Degree Of The Crime Of Fraud, Bribery, Arson Or Any Other Arson-related Crime In Connection With This Or Any Other Property? (in Ri, Failure To Disclose The Existence Of An Arson Conviction Is A Misdemeanor Punishable By A Sentence Of Up To One Year Of Imprisonment).?

Yes

No

5. Any Policy Or Coverage Declined, Cancelled Or Non-renewed During The Prior 3 Years? (not Applicable In Mo)

Yes

No

6. Do You Lease Employees To Or From Other Employers?

Yes

No

7. Any Workers Compensation Carried?

Yes

No

8. Do You Own Or Operate Any Other Business?

Yes

No

9. Any Other Insurance With This Company? (list Policy Numbers)

Yes

No

10. Are You Involved In Manufacturing, Mixing, Relabeling Or Repackaging Of Products?

Yes

No

11. Do You Rent Or Loan Equipment To Others?

Yes

No

12. Has Applicant Had A Foreclosure, Repossession, Bankruptcy, Judgement Or Lien During The Past Five (5) Years?

Yes

No

13. Any Exposure To Flammables, Explosives Or Chemicals?

Yes

No

14. Any Catastrophe Exposure?

Yes

No

15. Any Past Losses Or Claims Relating To Sexual Abuse Or Molestation Allegations, Discrimination Or Negligent Hiring?

Yes

No

16. Any Uncorrected Fire Code Violations?

Yes

No

Thank you filling your information

Our team will contact you soon.

If you have any query or concern, please contact us without any hesitate

Driver Information

City

State

What is driver gender?

Male

Female

Non-Binary

What is driver marital status?

Single

Married

Divorced

Widowed

Separated

Domestic Partner

State LIC

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Business Commercial General Information

1. With The Exception Of Any Encumbrances, Are Any Vehicles For Which Insurance Is Requested Not Solely Owned By And Registered To The Applicant?

Yes

No

2. Do Over 50% Of The Employees Use Their Autos In The Business?

Yes

No

3. Is There A Vehicle Maintenance Program In Operation?

Yes

No

4. Are Any Vehicles Leased To Others?

Yes

No

5. Any Car Modified / Special Equipment? (include Customized Vans / Pickups)

Yes

No

6. Are Icc (interstate Commerce Commission), Puc (public Utility Commission) Or Other Filings Required?

Yes

No

7. Do Operations Involve Transporting Hazardous Material?

Yes

No

8. Any Hold Harmless Agreements?

Yes

No

9. Any Vehicles Used By Family Members? If So, Identify.

Yes

No

10. Does The Applicant Obtain Mvr (motor Vehicle Record) Verifications?

Yes

No

11. Does The Applicant Have A Specific Driver Recruiting Method?

Yes

No

12. Are Any Drivers Not Covered By Workers Compensation?

Yes

No

13. Any Vehicles Owned But Not Scheduled On This Application?

Yes

No

14. Any Drivers With Convictions For Moving Traffic Violations?
Applicable Only In Kansas: Under Kansas Law, The Following Traffic Violations Are Not Required To Be Reported To Insurers:
1. A speeding violation of up to six (6) miles per hour (mph) that occurs in an area with a maximum posted speed limit from 30 mph through 54 mph, or
2. A speeding violation of up to ten (10) miles per hour (mph) that occurs in an area with a maximum posted speed limit from 55 mph through 75 mph.

Yes

No

15. Has Agent Inspected Vehicles?

Yes

No

16. Are All Vehicles To Be Included In This Policy Part Of A Fleet?

Yes

No

17. Do You Have Electronic Monitoring Devices That Record And Transmit Data In Any Of Your Vehicles?

Yes

No

Select

Vehicle Description

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