BUSINESS OWNER'S POLICY INDICATION FORM
 
 
 
 
 
 
Step 1: Eligibility
 
 
 
 
Line of Business:
 
Business Owner's Policy
 
 
 
Workers' Compensation
 
 
 
Industry
 
 
 
Classification
 
 
 
 
 
 
Step 2: Business Information
 
 
 
 
Coverage Start Date*
 
 
 
Business Name*
 
 
 
Street Address*
 
 
 
City*
 
 
 
State*
 
 
ZIP Code*
 
 
 
Years in Business*
 
 
Total Gross Annual Sales*
 
 
 
Full Time Employees
 
 
Part Time Employees
 
 
 
First Name*
 
 
Last Name*
 
 
 
Email*
 
 
Phone (xxx) xxx-xxxx*
 
 
 
 
 
 
Step 3: Premise Information
 
Please complete if you selected Business Owner's Policy in Step 1. Otherwise, please disregard.
 
 
 
 
Building Limit
 
 
Contents Limit (BPP)
 
 
 
Number of Stories
 
 
Year Building Built
 
 
 
Square Footage
 
 
Construction
 
 
 
 
 
 
Step 4: Workers' Compensation
 
Please complete if you selected Workers' Compensation in Step 1. Otherwise, please disregard.
 
 
 
 
Class
 
 
 
Description
 
 
 
Payroll