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Thank you for your interest in receiving a quote from Shield Insurance. This form should only take about 5-10 minutes to complete. Don't worry if you don't have everything. You can always click the "Save and continue later" button below. We'll email you a private link to pick up where you left off.

If you need a Bond click here to get started.

When do you want your policy to start?*

MM slash DD slash YYYY

What kind of business do you operate?*

Primary CategorySub Category

Which type of insurance are you looking for?*

Check all that apply. (A Business Insurance Policy combines General Liability and Commercial Property into one policy.)

General Liability

Business Insurance Policy

Commercial Auto

Professional Liability

Property

Disability

Bonds

Other

Other type of insurance*

To get an Insurance Bond click here to start our Bond Application Quote

Primary Insured Name*

First Last

Insured Date of Birth*

Month

Day

Year

Email*

Work Phone

Mobile Phone*

Can we text you?*

Yes

Please visit our Privacy Policy regarding Texting/SMS communication.

How were you referred to us?

Business Information

Legal Business Name*

Entity Type*

DBA*

Business Address*

Street Address City State Zipcode

Mailing Address*

Same as Business Address

Street Address City State Zipcode

Year Business Started*

Is there more than one owner of the business?*

Yes

Additional Business Owners

Additional Owners List

Owner Name	Email	Phone	Company Role	Actions

There are no Owners.

Maximum number of owners reached.

Vehicles

Are all vehicles garaged at the business address?*

Yes

Vehicles List

Year	Make	Model	VIN	Actions

There are no Vehicles.

Maximum number of vehicles reached.

Primary Insured Driver Info

Primary Insured: Drivers License Number*

Primary Insured: Drivers License State*

Commercial License? (CDL)

Yes

Year CDL Issued

Additional Drivers

Do any of your drivers take the vehicle(s) home at night?*

Yes

Have all drivers had a valid U.S. driver's license for at least 2 years?*

Yes

Drivers List

Driver Name	Date of Birth	Drivers License #	Drivers License State	Hire Date	Actions

There are no Drivers.

Maximum number of drivers reached.

Do you use contract or occasional drivers not listed above?*

Yes

How many drivers used annually?*

Auto Insurance

Name of owner*

Name of drivers*

Physical address*

Mailing address*

Vin number*

How much liability coverage*

If desired, what amount of Comprehensive/Collision coverage would you like?

Copy of your registration and driver's license. If you requested Comprehensive/Collision coverage, we need photos of all four sides of the vehicle.*

Drop files here or

Max. file size: 20 MB.

Business Information Continued

What is your total annual sales/revenue? (Gross)*

Do you have employee(s)?*

Yes

Owner payroll*

Number of employees*

Estimated annual payroll*

Do you hire temporary employees?*

Yes

Do you use any subcontractors? (1099s)*

Yes

Number of subcontractors*

Subcontractor annual payroll*

What type of work do your subs perform?*

Do you have a written contract with your subs requiring them to name your business as Additional Insured and show proof every year?*

Yes

Not yet

Trades Information

Construction of New Homes/Buildings

Remodeling / Renovation Work

Maintenance/Repair Work

Number of contractor licenses you currently hold*

Do operations include installation, service, or repair?*

Yes

Do business services include cleaning construction sites including debris removal?*

Yes

Do you perform snow and/or ice removal?*

Yes

Do you remove snow from streets or highways?*

Yes

Do operations involve the use of a crane?*

Yes

Do operations involve excavation?*

Yes

Select the types of excavation you perform

General excavation or trenching

Blasting

Dredging

Swimming pool excavation

Wrecking or demolition

Percentage of work involving excavation*

Do you use OSHA approved trenching/blasting safeguards?*

Yes

Do you demolish whole buildings or structures?*

Yes

Do jobs involve or expose employees to the following?

Select all that apply

Asbestos removal or exposure

Disaster recovery work

Fire, water, mold damage restoration or remediation

Lead paint removal

Oil, gas, or wells

Food and Beverage Information

Business is*

Fine Dining

Family Restaurant

Fast Food

Take out only

Bar/Tavern

with Food

without Food

Please review each section below and answer all questions that apply to your business.

Building & Exterior

Construction

Frame

Masonry

Fire Resistive

Other

Other construction type

Roof

Pitched

Flat

Metal

Shingled

Concrete

Other

Other roof type

Number of Stories

Living quarters in building?

Yes

Parking area and entrance well lit?

Yes

Are building and outdoor premises well maintained?

Yes

Steps, walks, and parking free from trip hazards?

Yes

Exterior glass undamaged?

Yes

Signs in good condition?

Yes

Freestanding

On Building

Garbage area well maintained?

Yes

Exterior Comments

Interior Information

Lighted exit signs on all exits?

Yes

Exits clear and accessible?

Yes

Equipped with emergency lighting?

Yes

Interior steps safe and well lit?

Yes

Flooring free from trip hazards?

Yes

Furniture in good condition?

Yes

Ceiling in good condition?

Yes

Restrooms clean and dry?

Yes

Self service area clean?

Yes

Interior Comments

Exposures

Surrounding neighborhood is

Residential

Mercantile

Industrial

Mixed

Surrounding condition is

Improving

Stable

Deteriorating

Is property/premises located near/on/over water?

Yes

Distance to water

Is there a pool on the property?

Yes

Is the pool accessible to patron?

Yes

Adjacent Exposures (Front Side)

Adjacent Exposures (Left Side)

Adjacent Exposures (Right Side)

Adjacent Exposures (Rear Side)

Additional Exposures Comments

Fire and Safety

Fire Extinguishers (type, quantity, size, location, and tag date)

Sprinkler System

None

Partial

Full

Are all electrical outlets covered and not overloaded?

Yes

Is all wiring on circuit breakers?

Yes

Is water heater in good condition and free from combustibles?

Yes

Fire and Safety Comments

Entertainment and Amusement

Type(s) of Entertainment

Band

Comedy

Amateur Night

Nude Dancers

Other

Nights per week

Any audience participation?

Yes

What type of audience participation?

Dance Floor Size (if any)

Enter width and length in feet.

Are dartboard out of traffic area?

Yes

Number of Pool Tables

Other types of amusement

Examples: Juke Box, Video Games, Pinball, etc.

Seating Capacity and Area

Seating Capacity (main floor, 2nd floor, outdoor seating, lounge, banquet room)

Area (main floor, 2nd floor, outdoor seating)

Total

Kitchen

Is there a metal hood covering all cooking equipment?

Yes

Are all open flame cooking devices (grills, fat fryers) covered by automatic fire suppression?

Yes

Fire suppression tag date (if applicable)

Do non combustable materials surround cooking equipment?

Yes

Are there high temperature cut-off switches on deep fat fryers?

Yes

Are filters in the hood clean and free of grease build up?

Yes

Kitchen Rating

Excellent

Above Average

Average

Below Average

Poor

If below average or poor explain why

Management Interview

Person Interviewed

Position

Business is

Sole Proprietorship

Partnership

Corporation

Owner has been here for how long? (in years)

Owner/Manager has how much experience in this business? (in years)

Hours of operation

Is this risk seasonal?

Yes

Are any other properties/businesses owned by insured?

Yes

Is the property under the same entity name?

Yes

Insured

Owns building

Leases building

Is space leased to others?

Yes

Distance to fire department (in miles)

Is a wrench kept near the gas cutoff?

Yes

Age of building

If over 25 years, when has the electrical, plumbing, and roof been updated?

How often are filter in the hood cleaned?

How often is the fire suppression serviced?

Is fire suppression system under a maintenance contact?

Yes

Where is used grease stored?

Outside in drum

Dumpster

Other

How often are bathrooms inspected?

Do you mop during open hours?

Yes (with "wet floor" sign)

Yes (no sign)

Valet parking by?

Employees

Contracted

None

Number of attendants

Lot on premises?

Yes

Car keys kept in

Car

Locked box

Other

Any liquor license violations?

Yes

Explain

Name as it appears on liquor license

Any specials on liquor?

2 for 1

Happy Hour

Shooters

Ladies Night

Other

Are bouncers used for disturbance?

Yes

Are security guards employed?

Yes

Are police called to handle disturbances?

Yes

How many times were police called in the past 365 days (approx)

What type of alarm is present?

None

Burglar

Fire

Hold-up

Is it a central station alarm?

Yes

Are there firearms on the premises?

Yes

Any guard dogs kept on the premises?

Yes

Is there a safe on the premises?

Yes

Maximum amount kept in safe overnight? (if used)

How often are deposits made?

Maximum amount kept in registers

Are references checked before hiring a new employee?

Yes

Checks stamped "For Deposit Only" on receipt?

Yes

Does insured provide delivery of food or liquor?

Food

Liquor

Both

Delivery vehicle

Company car

Employee car

Is package liquor/wine/beer sold?

Yes

Any catering done off premises?

Yes

Type of events

Do you provide liquor

Yes

Do you provide entertainment

Yes

Gross annual receipts (Food)

Gross annual receipts (Liquor)

Gross annual receipts (Package liquor)

Gross annual receipts (Catering)

Gross annual receipts (Other)

Gross annual receipts (Total)

Gross annual receipts (Catering)

Building and Property Information

My business location is*

Leased Property

Owned Property

Work From Home

Do you need property coverage for the building?*

Yes

Property Liability Limit*

Have you made any tenant improvements?*

Yes

In the future

How much tenant improvement coverage do you need?

Square footage of your business*

Building Information

Is building rented to others?

Yes

Please describe renting building to others

Date Purchased (if applicable)

MM slash DD slash YYYY

Date of major improvements and nature of improvements (if applicable)

Year Built*

Number of stories of the building*

Roof Structure*

Roof Anchor Systems

Other Roof Anchor System*

Laths or Purlins*

Roof Covering Type*

Other Roof Covering Type*

Roof Cover Fastenings*

Intervals Between Fastenings*

Other Roof Cover Fastenings*

If over 8 inches please specify distance between fastenings*

Exterior Walls*

Other exterior wall type*

Does property have hurricane shutters?*

Yes, Fully

Yes, Partially

Exterior Opening Protection

Roof Type Steel

Hinged Wood (permanent)

Steel Panels (portable)

Anchor bolts to receive plywood

Other

None

Other exterior opening protection

Iron Grill Work

Yes

Aluminum "Miami" Louvers

Yes

Has there been any updates to the roof, plumbing, or electrical?*

Yes

I don't know

Year Roof Updated?

Roof Update Type*

Full

Partial

Year Electrical Updated?

Electrical Update Type*

Full

Partial

Year Plumbing Updated?

Plumbing Update Type*

Full

Partial

Fire Extinguishers

Yes

Number of Fire Extinguishers

Smoke Detectors

Yes

Number of Smoke Detectors

Burglar Alarm System

Yes

Distance to Fire Department (in miles)

Business Description

Please describe the nature of your business*

Please be descriptive as this will prevent additional underwriting questions and delays.

Manufacturing

Is there any manufacturing, mixing, re-labeling, or repackaging of products?*

Yes

Human & Social Services Information

Does your business have a state license?*

Yes

State License #*

License Capacity*

Does your business provide child care?*

Yes

Childcare Information

Current maximum number of children you care for at one time*

Does the provider live in the home where the child care is provided?*

Yes

Does the provider provide 24-hour care or overnight care?*

Yes

Does the provider have any swimming facility besides an 18 inch deep plastic wading pool?*

Yes

Does the provider have someone to watch the children in an emergency that causes you to leave the daycare location?*

Yes

Does the provider accept borders in their home?*

Yes

Has the business' childcare license, certification, or registration ever been suspended or revoked?*

Yes

Has the business' childcare insurance ever been cancelled or non-renewed?*

Yes

Has the business had any claims against them in the last 5 years, or do they or their employees know of any incident that could result in a claim?*

Yes

Liability Limits (optional)

What is the General Liability limit requested?

Do you need any Business Personal Property coverage?*

Yes

Not sure, let's discuss

How much Business Personal Property coverage do you want?

Are you interested in Loss of Use / Business Income coverage?*

Yes

Not sure, let's discuss

How much Loss of Use coverage do you want?

Additional Insured Information (optional)

Do you have anyone that needs to be listed as Additional Insured?

Yes

Additional Insured Information. (i.e. Name & Address)

You may upload your additional insured documents using the upload field below.

Additional Insured Document(s)

You may upload up to 10 PDF documents. If you have more documents you can send them to your agent after they contact you.

Drop files here or

Accepted file types: pdf, Max. file size: 20 MB, Max. files: 10.

Claims Information

Have you had any claims or losses in the last 5 years?*

Yes

What was the date, amount paid, and description of each loss or claim*

Is the business a subsidiary of another entity?*

Yes

Does the business have any subsidiaries?*

Yes

Is a formal safety program in operation?*

Yes

Any exposure to flammables, explosives, or chemicals?*

Yes

Has your business been cancelled or non-renewed in the last 4 years?*

Yes

Has the applicant had a foreclosure, repossession, bankruptcy, or filed for bankruptcy during the last 5 years?*

Yes

Bankruptcy: Please describe when and why*

Has the applicant had a judgement or lien during the last 5 years?*

Yes

Has the business been placed in a Trust?*

Yes

Name of Trust*

Any foreign operations, foreign products distributed in USA, or US products sold/distributed in foreign countries?*

Yes

Does the applicant have other business ventures for which coverage is not requested?*

Yes

Do you have ANY business insurance currently?*

Yes

Do you have ANY previous business insurance from the past 3 years?*

Yes

Current Insurance

Name of current insurance carrier?*

Expiration date of current policy*

MM slash DD slash YYYY

Current total insurance premium?

Current Policies

Drop files here or

Accepted file types: pdf, Max. file size: 5 MB, Max. files: 10.

Prior Insurance

Please enter your prior business insurance information below.

Prior Carrier Name 1

Policy Year 1

Premium 1

Prior Carrier Name 2

Policy Year 2

Premium 2

Prior Carrier Name 3

Policy Year 3

Premium 3

Any past losses or claims relating to sexual abuse or molestation allegations, discrimination, or negligent hiring?*

Yes

In the past 5 years 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?*

Yes

Any uncorrected fire and/or safety code violations?*

Yes

Additional Comments and/or Documents (optional)

Any additional comments

Any Additional Documents

Photos needed: Exterior of property on all 4 sides showing wall to wall (showing all windows and doors). Interior - one picture of each room.

Drop files here or

Max. file size: 1 MB.

Wrapping Up

Consent*

Like most insurance agencies, we use information from you and other sources, such as your driving and claims histories, insurance score, and other factors to calculate an accurate rate for your insurance. New or updated information may be used to calculate your renewal premium.

I Agree

All the above information is accurate and true to the best of my knowledge.*

Yes

View Insurance Fraud Statement

Personal Insurance