Fillable Home Business Insurance Application (Risk Placement Services, Inc.)

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Home Business Insurance Application (Risk Placement Services, Inc.)

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ANY CHANGES MADE TO AN ANSWER ON THIS APPLICATION MUST BE INITIALED BY THE APPLICANT
Desired
Effective Date:
Page 1 of 4 Pages
PLEASE COMPLETE AND SIGN THE APPLICATION
HBP 108 (01/10)
Agency Name
City State Zip
Address
RLI Administrator/Brokering Agent Number
RLI Insurance Company
Peoria, Illinois
Home Business Insurance Application
Premium $
WEBSITE ADDRESS_____________________________
APPLICANT INFORMATION - Please answer each question completely.
NAMED INSURED (if a partnership, please provide all individual's names):
BUSINESS NAME: EMAIL ADDRESS ______________________________
PHONE:
MAILING ADDRESS:
FOR TEXAS & NEW JERSEY
RESIDENTS ONLY
County Name
Frame
Masonry
Construction (For Texas Only)
CORRESPONDING ELIGIBILITY
CLASS OF BUSINESS NUMBER
PER HBP-117:
LOCATION ONE PROPERTY ADDRESS, if different from mailing address:
INCLUDE A DETAILED BUSINESS DESCRIPTION INCLUDING PRODUCTS AND SERVICES YOU SELL UNDER
THIS ENTITY.
PLEASE CHECK BOX APPLICABLE TO NAMED INSURED:
INDIVIDUAL PARTNERSHIP/JOINT VENTURE CORPORATION/ORGANIZATION (Any Other) LLC
Property (No Building Coverage)
LIMITS/COVERAGE REQUESTED
General Liability
Business Liability each occurrence
$300,000 $500,000 $1,000,000
(Medical payments of $5,000 each person included)
Class limitations and exclusions may apply.
Deductible
Standard Deductible is $250
(No other deductible available)
LOCATION TWO PROPERTY ADDRESS, SEE PAGE 3 FOR 2nd LOCATION UNDERWRITING QUESTIONS:
DO YOU OPERATE ANY OTHER BUSINESS FROM YOUR RESIDENCE THAT IS NOT INDICATED IN THE DETAILED BUSINESS DESCRIPTION ABOVE?
Yes No If yes, what is the entity of this business?
Please provide a detailed description of this other business:
Individual Partnership/Joint Venture Corporation/Organization (Any Other) LLC
Business Personal Property (BPP)
on premises and while temporarily off premises.
Must equal 100% of replacement cost.
Location One BPP Coverage Limit $__________________
(Minimum limit $5,000)
Location Two BPP Coverage Limit $__________________
(Minimum limit $5,000)
(Total BPP Coverage limits may not exceed the maximum
limit of $100,000)
WEBSITE ADDRESS_____________________________
APPLICANT INFORMATION - Please answer each question completely.
NAMED INSURED (if a partnership, please provide all individual's names):
BUSINESS NAME: EMAIL ADDRESS ______________________________
PHONE:
MAILING ADDRESS:
FOR TEXAS & NEW JERSEY
RESIDENTS ONLY
County Name
Frame
Masonry
Construction (For Texas Only)
CORRESPONDING ELIGIBILITY
CLASS OF BUSINESS NUMBER
PER HBP-117:
LOCATION ONE PROPERTY ADDRESS, if different from mailing address:
INCLUDE A DETAILED BUSINESS DESCRIPTION INCLUDING PRODUCTS AND SERVICES YOU SELL UNDER
THIS ENTITY.
PLEASE CHECK BOX APPLICABLE TO NAMED INSURED:
INDIVIDUAL PARTNERSHIP/JOINT VENTURE CORPORATION/ORGANIZATION (Any Other) LLC
Property (No Building Coverage)
LIMITS/COVERAGE REQUESTED
General Liability
Business Liability each occurrence
$300,000 $500,000 $1,000,000
(Medical payments of $5,000 each person included)
Class limitations and exclusions may apply.
Deductible
Standard Deductible is $250
(No other deductible available)
LOCATION TWO PROPERTY ADDRESS, SEE PAGE 3 FOR 2nd LOCATION UNDERWRITING QUESTIONS:
DO YOU OPERATE ANY OTHER BUSINESS FROM YOUR RESIDENCE THAT IS NOT INDICATED IN THE DETAILED BUSINESS DESCRIPTION ABOVE?
Yes No If yes, what is the entity of this business?
Please provide a detailed description of this other business:
Individual Partnership/Joint Venture Corporation/Organization (Any Other) LLC
Business Personal Property (BPP)
on premises and while temporarily off premises.
Must equal 100% of replacement cost.
Location One BPP Coverage Limit $__________________
(Minimum limit $5,000)
Location Two BPP Coverage Limit $__________________
(Minimum limit $5,000)
OPTIONAL COVERAGES: Please review the below listing of optional coverages available. Then select coverages which are desired by checking
the box and filling in the requested coverage amount.
Requested Optional Coverage Amount:Optional Coverages:
Jewelry and Watch Increased Theft Coverage ($250 Limit)
Money & Securities (On/Off Premises): $1,000/$1,000 $2,000/$1,000 $3,000/$1,000
$4,000/$1,000 $5,000/$2,000 $7,500/$2,000 $10,000/$5,000
Please carefully read questions 1 through 16 and respond by checking (X) the appropriate YES or NO box. If any question 1 through
16 is answered YES or is not answered, you will not be eligible for coverage and this application should not be submitted to RLI.
GENERAL UNDERWRITING INFORMATION:
1. Is your business property permanently kept anywhere other than this residence (residence includes outbuildings
within 100 ft) or the second location identified on page 1 of this application?.................................................................
2. Have you had more than two claims of any type, related to your business operation, in the last three years? .................
3. Have you had a single claim, related to your business, for more than $25,000 in the last three years? ...........................
4. Do you own any business under the same legal name as the "Business Name" shown, which is permanently
"operated" from a second location? (Note: Check "NO" if you have a storage location, second home or a partner
working from their home. These are acceptable and should be listed as a second location on page 1 of this
application.).......................................................................................................................................................................
5. Do you repackage food or personal care products to be sold under your own label? .......................................................
6. Are you involved in the sale or manufacturing of explosives, propellants and/or use of flammable liquids? .................
7. Do you install any products, excluding the installation of computer systems, office equipment, key-locking devices,
interior window treatments or vinyl signs and lettering? .................................................................................................
8. 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.)
9. Did your gross annual sales/receipts from your business pursuits for the most recent calendar year exceed
$250,000 for sale of merchandise or $500,000 for a service business?.............................................................................
Total estimated annual revenues ....................................................................$________________
Estimated annual revenues from your manufactured products.......................$________________
10. Do you employ more than ten (10) employees, other than independent contractors or distributors?..............................
11. Is your dwelling located within 1,500 feet from the seacoast on the Gulf of Mexico or the Atlantic Ocean (N/A in RI)?
12. If you are a teacher/tutor (other than a personal fitness trainer), do you provide instruction for sports, physical
education, industrial arts, or martial arts? (Note: Check "NO" if this question is not applicable to your business.).........
13. Do you perform any vehicle repair services (other than oil changes, oil filter changes, glass repair, interior detailing
or vinyl/leather repair)?.....................................................................................................................................................
14. Do you perform any of the following?..............................................................................................................................
Body Massage (other than face, scalp or hand); Hair Straightening by other than cold process; Tanning;
Microdermabrasion; Acid Peels; Hair Replacement; Hair Removal (by electrolysis, thermolysis, or any process using
radio waves); Ear Candling, Tattooing or Permanent Make-up; Ear or Body Piercing; Hydrotherapy/Saunas; or Body
Waxing (other than facials).
15. Do you own or operate any other business under this entity that has not already been described on this application?....
16. Are you an importer of foreign products?.........................................................................................................................
Page 2 of 4 Pages HBP 108 (01/10)
Manager or Lessor of Premises
ADDITIONAL INSURED/LOSS PAYEE INFORMATION
Lessor of Leased Equipment
Additional Insured Loss Payee
Controlling Interest in this business
Co-owner of Insured Premises
Owner or Lessor of Leased Land
Grantor of Franchise
State/Political Subdivision (for
permits relating to the premises)
Additional Insured Name
Address City State & Zip
Loss Payee Name
Address City State & Zip
What interest does the additional insured have in the insured's business? (Response is mandatory.)
Dispatcher or Referral Service (Blanket Form)
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
Dispatcher or Referral Service (Scheduled Form)
Grantor of License
IDENTITY FRAUD EXPENSE COVERAGE
Identity Fraud Expense Coverage ($25,000 Limit)
YES NO
Is there any reason to believe that the business or any of its owners, officers, partners or employees have been a victim of identity theft in the past 5
years? (If "YES", attach a statement regarding the scope of the incident and how it has been resolved.)
GARAGEKEEPERS COVERAGE
Page 3 of 4 Pages HBP 108 (01/10)
17. Do you have a contractor's license?..................................................................................................................................
If yes, please provide the following information:
License #_____________________ Jurisdiction______________________ Category_____________________
Question 17 may be answered YES or NO. If YES is selected the license, jurisdiction and category section must be completed; once
the application is submitted underwriting will review for eligibility.
YES NO
If a second location has been added to page 1 of this application, please complete the following questions. Please note: Risks may
store BPP at a second location, but may not operate their business from a second location; other than a secondary residence.
Store front locations are not eligible.
2nd LOCATION UNDERWRITING QUESTIONS:
1. Do you operate your business from a store front location?...............................................................................................
2. Do you rent or own a second residence?...........................................................................................................................
3. Do you have a partner that works directly from their own residence? (Note: If more than two owners you must
contact RLI for approval to add an additional location.)...................................................................................................
4. Do you rent or own a storage unit (maximum size: 250 sq ft.)?........................................................................................
5. Do you store BPP in an outbuilding located more than 100 ft. away from your residence? (Note: an outbuilding
within 100 ft. from your residence does not need to be added as a 2nd location).............................................................
YES NO
YES NO
YES NO
YES NO
YES NO
Select Limit
As part of your operations, what is the greatest number of vehicles in your care, custody or control at any covered location, at any one time?
One vehicle - may select $30,000 or $60,000 limit - please indicate limit:
$30,000
$60,000
Two to four vehicles - $60,000 limit is mandatory
More than four vehicles - not eligible for garagekeepers coverage
Locations for Garagekeepers Coverage
List all locations that you own or lease where you will conduct garage operations and describe the type of operations you will conduct at each
location. ---AND--- List all other locations where you have, or will, conduct garage operations on more than 30 days in any 12-month period:
Please describe the nature and ownership of this location (e.g., county fairgrounds, John Doe's home, etc.)
Select Coverage Option
Coverage is available for comprehensive and collision causes of loss. Please indicate the desired coverage option:
Legal liability
Direct coverage - primary basis (without regard to legal liability)
Direct coverage - excess over customer's policy (without regard to legal liability)
Comprehensive losses are subject to a $250 per auto and $1,000 maximum deductible for any one event.
Collision losses are subject to a $250 per auto deductible.
Location Number:
Street, City, State, ZIP:
Describe operations conducted at this location:
Location Number:
Street, City, State, ZIP:
Describe ownership and nature of this location:
Describe operations conducted at this location: Describe ownership and nature of this location:
Location Number:
Street, City, State, ZIP:
Describe operations conducted at this location: Describe ownership and nature of this location:
OPTIONAL
Do you belong to a trade association, regularly visit a website, or receive a publication related to your Home
Business? Please provide name and/or website address.
________________________________________________________________________________________
APPLICANT'S STATEMENT:
IMPORTANT: The statements (answers) given above are true and accurate. The applicant has not willfully concealed or misrepresented
any material fact or circumstance concerning this application. This application does not constitute a binder.
FRAUD WARNING: Any person who knowingly and with intent to defraud any insurance company or other person files an application for
insurance or statement of claim containing any materially false, incomplete, or misleading information, or conceals information concerning
any material fact thereto, commits a fraudulent insurance act, which is a crime punishable by incarceration, and shall also be subject to civil
penalties. (Not applicable in LA, MD, NM, OK, PA, TN, VA, and WA.)
MD: Any person who knowingly and willfully presents a false or fraudulent claim for payment of a loss or benefit or knowingly and
willfully presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison.
LA, NM: Any person who knowingly presents a false or fraudulent claim for payment of a loss or benefit or knowingly presents false
information in an application for insurance is guilty of a crime and may be subject to fines and confinement in prison (NM: civil fines and
criminal penalties).
OK: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any claim for the proceeds of an insurance
policy containing any false, incomplete or misleading information is guilty of a felony.
PA: Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or
statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact
material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties.
TN, VA, WA: It is a crime to knowingly provide false, incomplete or misleading information to an insurance company for the purpose of
defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
APPLICATION WILL NOT BE ACCEPTED WITHOUT APPLICANT'S ORIGINAL SIGNATURE.
Date: _______________________________ Applicant's Original Signature: ___________________________________________
Date: _______________________________ Producer's Signature: ____________________________________________________
NO INSURANCE WILL BE IN EFFECT UNTIL RLI INSURANCE COMPANY ISSUES A POLICY.
Page 4 of 4 Pages HBP 108 (01/10)
Agent's License Number: ________________________________________________
(Required if the Applicant resides in the state of Florida.)
ANY CHANGES MADE TO AN ANSWER ON THIS APPLICATION MUST BE INITIALED BY THE APPLICANT
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Home Business Insurance Application (Risk Placement Services, Inc.)

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Completed 30 July 2020

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