[Breathe – BOPAmaInt] – Purely Insurance

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Purely Business Owner’s Policy Application

"*" indicates required fields

What kind of work do you do?

What is your Industry?*

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NAICS

Primary Business Description*

What coverage do you need help with?*

General Liability

Commercial Property

Commercial Auto

Workers Comp

Professional Liability

Group Health Insurance

Your Company Information

Business Name

Do you have a DBA Name (Doing Business As)*

Yes

No

What is your DBA Name?

Business Website

Business Entity Type*

Individual (Sole Proprietor)

Partnership

Corporation

LLC

Other

What Entity Type is the Business?

What is the Tax ID?

Business Physical Address

Street Address City State ZIP Code

Business Mailing Address

Same as previous

Street Address Address Line 2 City State ZIP Code

What year did the business start?

How many years of experience do you have?

Estimated Annual Gross Sales

Estimated Annual Payroll

Do you hire Sub Contractors?*

Yes

No

Do you Require the Sub Contractors to provide a Certificate of Insurance?*

Yes

No

Do you Require Sub Contractors to list you as Additional Insured?*

Yes

No

Estimated Annual Subcontractor Cost

Briefly describe business operations*

Has any policy been cancelled or non-renewed in the past 3 years?

Yes

No

Describe reason for cancellation or non-renewal

Did you have any claims in the past 5 years?

Yes

No

Describe claims in the last 5 years with amount paid for each loss or claim.

Do you own 50% or more in another business?

Please describe other business ownership

General Liability

Select General Liability Limit*

Do you need a higher limit of Liability?

Yes

No

Select an Excess or Umbrella Liability Limit

Do you manufacture or offer private labeled products?

Yes

No

Commercial Property

Do you lease or own the building your business occupies?

Own

Lease

Home Based

Do clients come to your home?

Yes

No

Add Building or Business Property

Scheduled Equipment

Commercial Auto

Vehicle Schedule

Driver Schedule

Workers Comp

What is your current Work Comp Policy Status?*

Active

Expired or Canceled

My first-time getting Work Comp

Workers Comp Policy Expiration Date*

MM slash DD slash YYYY

Do you know what your Experience Mod is?*

Yes

No

What is your current Experience Mod?

Owner

Employee Classification & Payroll

Comments

Is there anything specific that you would like us to know?

Upload Dec Pages / Loss Runs or other documents if applicable

Drop files here or

Max. file size: 128 MB.

Your Information

First Name

Last Name

Phone

Email

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EZLynxAppID

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contactId

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ownerEmail

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Coterie ID