New Business Quote Request Form – Auto/WC

New Business Quote Request Form - Auto/WC

A separate form is used for Auto/WC underwriting service requests: click here.

This form does NOT replace the requirement to complete the appropriate Auto/WC application(s). If binding new Auto/WC business, please reply to the quote email instead of using this form.

For the package, our core insurance program, please submit your request via Origami. (If binding new Auto/WC business, please reply to the quote email instead of using this form. For the package, our core insurance program, please submit your request via Origami.)

Agent/Agency Name(Required)

Other Agent/Agency(Required)

Your Name(Required)

Your Email Address(Required)

Enter only one valid email address. A copy of the submission will be sent to this email address.

Participant/Church IB#

If known.

Participant/Church Name(Required)

As shown on the MOI.

Participant FEIN(Required)

Participant Address(Required)

Physical Address (not Mailing Address)

Participant/Church City(Required)

Participant/Church State(Required)

Participant Zip Code(Required)

Participant Website

Which application(s) is/are being submitted?(Required)

Auto Application

Workers' Compensation (WC) Application

Note an application must also be submitted. Select the appropriate application(s) you're looking to submit and complete the application details within this form.

Effective Date

If not applicable, enter need by date.

Need By Date(Required)

At least 15 business days out is the norm.

Is this a Rush Request?(Required)

Yes

If less than 5 business days. Requests will be treated as rushes ONLY IF a reason for the rush is described below and a need by date is provided.

Participant/Church Email Address

For Loss Control Resources.

Target Owned Auto and WC Premium?

Auto Application Details

List all drivers Including family members who drive company vehicles. (Minimum one driver needed). Attach additional page or use the Remarks section at the end of this application if necessary.

List all drivers Including family members who drive company vehicles. (Minimum one driver needed). Attach additional page or use the remarks section at the end of this application if necessary.(Required)

Name

City

State

Zip

Date of Birth

Driver's License #

State Licensed

Are MVRs pulled annually?(Required)

Yes

Do all drivers have a valid U.S. driver’s license(Required)

Yes

Do any drivers require an individual financial responsibility filing (e.g. SR-22), other than a Form E filing?(Required)

Yes

Do any volunteers or employees, NOT listed above, ever drive a company vehicle?(Required)

Yes

Do any volunteers or employees transport children?(Required)

Yes

Are background checks done annually?(Required)

Yes

Are waivers signed by parents?(Required)

Yes

Do they have any one-on-one contact?(Required)

Yes

List all owned and leased (long-term) vehicles. (Minimum one vehicle needed). Attach additional page or use the remarks section at the end of this application if necessary.(Required)

Veh No.

Year

Make

Model

VIN

Cost New

# of Seats

Weight (lbs)

Radius

Garaging Zip Code

Comp. Ded

Coll. Ded

Do any vehicles have a Loss Payee?(Required)

Yes

List Loss Payees for each vehicle. Attach additional page or use the Remarks section at the end of this application if necessary.(Required)

Veh No.

Loss Payee Name

Address

City

State

ZIP

Please upload loss history for the last five years(Required)

Drop files here or

Max. file size: 50 MB.

Vehicle Operations (Select all that apply)

Errands & meetings

Personal Use Only

Transport adults to/from services or activities

Transport children

Trailer used to carry tools/equipment to job sites

Trailer used to deliver products or serve food

Trailer used for offices or mobile showrooms

Other

Other Vehicle Operations(Required)

Additional Details Regarding Vehicle Operations(Required)

Applicant’s commitment to safety and proper maintenance include: (select all that apply & be prepared to provide evidence)(Required)

Additional Remarks

Upload Additional Documentation (optional)

Drop files here or

Max. file size: 50 MB.

Do not attach copies of driver's licenses.

Fraud Warnings & Signature(Required)

Check here if you have read and understand the following applicable statement(s) about fraud:

Any person who knowingly and with intent to defraud any insurance company or another 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 the person to criminal and civil penalties.
Applicable in AL, AR, DC, LA, MD, NM, RI and WV: Any person who knowingly (or willfully) * presents a false or fraudulent claim for payment of a loss or benefit or knowingly (or willfully) * presents false information in an application for insurance is guilty of a crime and may be subject to fines and confinement imprison. *Applies in MD Only.

Applicable in CO: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance and civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a settlement or award payable from insurance proceeds shall be reported to the Colorado Division of Insurance within the Department of Regulatory Agencies.
Applicable in FL and OK: Any person who knowingly and with intent to injure, defraud, or deceive any insurer files a statement of claim or an application containing any false, incomplete, or misleading information is guilty of a felony (of the third degree) *. *Applies in FL Only.
Applicable in KS: Any person who, knowingly and with intent to defraud, presents, causes to be presented or prepares with knowledge or belief that it will be presented to or by an insurer, purported insurer, broker or any agent thereof, any written statement as part of, or in support of, an application for the issuance of, or the rating of an insurance policy for personal or commercial insurance, or a claim for payment or other benefit pursuant to an insurance policy for commercial or personal insurance which such person knows to contain materially false information concerning any fact material thereto; or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act.

Applicable in KY, NY, OH and 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 (not to exceed five thousand dollars and the stated value of the claim for each such violation)*. *Applies in NY Only.
Applicable in ME, TN, VA and 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 (may)* include imprisonment, fines and denial of insurance benefits. *Applies in ME Only.
Applicable in NJ: Any person who includes any false or misleading information on an application for an insurance policy is subject to criminal and civil penalties.

Applicable in OR: Any person who knowingly and with intent to defraud or solicit another to defraud the insurer by submitting an application containing a false statement as to any material fact may be violating state law.

Applicable in UT: Any person who knowingly presents false or fraudulent underwriting information, files or causes to be filed a false or fraudulent claim for disability compensation or medical benefits or submits a false or fraudulent report or billing for health care fees or other professional services is guilty of a crime and may be subject to fines and confinement in state prison.

THE UNDERSIGNED IS AN AUTHORIZED REPRESENTATIVE OF THE APPLICANT AND REPRESENTS THAT REASONABLE INQUIRY HAS BEEN MADE TO OBTAIN THE ANSWERS TO QUESTIONS ON THIS APPLICATION. HE/SHE REPRESENTS THAT THE ANSWERS ARE TRUE, CORRECT AND COMPLETE TO THE BEST OF HIS/HERKNOWLEDGE.

Workers' Compensation (WC) Application Details

Payroll Information

Payroll: Religious Organization Pastor of Professional Employees (8868) (enter N/A if non-applicable)(Required)

Payroll: Religious Organization - All Other Employees (9101) (enter N/A if non-applicable)(Required)

Payroll: Childcare (8869) (full-time/part-time daycare. Not Sunday Nursery School) (enter N/A if non-applicable)(Required)

Payroll: Camp (9015) (enter N/A if non-applicable)(Required)

Payroll: Labor (1099) (enter N/A if non-applicable)(Required)

# of Full Time Employees(Required)

# of Part Time Employees(Required)

# of Officers(Required)

Current Worker’s Compensation Carrier

Carrier Name(Required)

Term(Required)

Premium(Required)

Do you have any losses within the last 5 years?(Required)

Yes

Provide a copy of loss runs(Required)

Drop files here or

Max. file size: 50 MB.

Provide more information regarding the claims, what has been done to mitigate them in the future.(Required)

Does participant operate an elderly/child daycare?(Required)

Yes

Do any of your employees set up or tear down stage materials for any off-site events?(Required)

Yes

Do you sponsor any off-site events for employees like sporting events, visits to sports venues, etc?(Required)

Yes

Do your maintenance employees do any roof work or work at heights (even setting up decorations for holidays, etc)?(Required)

Yes

Do employees do any community service work throughout the city?(Required)

Yes

What type of work do they do?(Required)

Does participant provide any counseling services?(Required)

Yes

Does the church run anything like a food kitchen or pantry?(Required)

Yes

Does participant transport employees in groups in large passenger vans?(Required)

Yes

Does participant have employees that lead mission trips out of the country?(Required)

Yes

What countries?(Required)

Do participant's employees perform grounds maintenance, landscaping, ice removal, etc?(Required)

Yes

Do they operate any kitchens?(Required)

Yes

Does participant have security/police monitor collections and money deposits?(Required)

Yes

How is money handled? Is it by employees only?(Required)

Does participant provide televised services?(Required)

Yes

Is there a production staff that operates and moves cameras and other equipment?(Required)

Yes

What is estimated average age of employees?(Required)

Describe the pre-employment screening process.(Required)

Describe the training and selection of church employees.(Required)

Are we covering any volunteers?(Required)

Yes

Is the security staff employed by the church?(Required)

Yes

Are they armed?(Required)

Yes

What are the hours of the security staff?(Required)

Describe the security staff’s responsibilities.(Required)

What are the hours and days of church operations?(Required)

Upload Additional Documents (optional)

Max. file size: 50 MB.

Additional Comments or Instructions

File

Max. file size: 50 MB.

Name

This field is for validation purposes and should be left unchanged.