New Brokered Submission

Insured Information

0 / 6

Insured Name

—

DBA

—

Entity Type

—

FEIN

—

Year Established

—

Contact Phone

—

Contact Email

—

Physical Address

not validated

Street

—

Suite

—

County

—

City

—

State

—

Zip

—

Mailing Address

Same as physical address

Street

—

City / State / Zip

—

Policy Details

Effective Date

—

Expiration Date

—

Term

—

Lines of Business

General Liability Property Workers' Compensation

General Liability

pending

Class Code

—

Class Description

—

Basis

—

Gross Sales (annual)

—

Payroll (annual)

—

Square Feet

—

Each Occurrence

—

General Aggregate

—

Products/Completed Ops

—

Property (Location 1 of 1)

pending

Construction

—

Year Built

—

Square Feet

—

Building Limit

—

BPP Limit

—

Protection Class

—

Sprinklered

—

Occupancy

—

Roof Age

—

Workers' Compensation

pending

Extracted from WC_Employee_Roster.xlsx — format flexible, no ACORD 130 required

Employee	Role	Class	Payroll
Total Payroll · 9 employees · Exp. Mod 0.92			$301,000

Submission Notes

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