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Fields marked (*) are mandatory.
Concierge/Errand Services Application
Name:*
Website:
Address:*
City:*
State:*
Zip:*
Phone Number:
Fax Number:
Is Applicant
Number of Owners:
Number of Full Time Employees
Number of Part Time Employees
Number of Sub-Contractors
Years In Business:
Annual Receipts/Sales:
Annual Payroll:
Sub-Contractor Costs:
Is the Applicant Involved with:
A. Any event planning exposures involving more than 25 attendees?
If So, % of annual sales:
B. Any Catering operations or ownership/leasing of Halls:
If so, % of annual sales
(If Yes, supplemental application(s) required and these exposures will be seperately rated and charged for.)
Prior Insurance Carrier:
Has any previous carrier refused to renewl or cancelled coverage:
Any losses in the past 3 years: (If Yes, describe in remarks section & indicate amounts incurred.)
Limits of Liability
$2,000,000 General Aggregate
$1,000,000 Products/Completed Operations Aggregate
$1,000,000 Personal & Advertising Injury
$1,000,000 Each Occurrence
$ 100,000 Fire Damage
$ 5,000 Medical Expense
$ 25,000/$50,000 Sexual/Physical Abuse Coverage (Subject to form)
Deductible Nil
$10,000 Occurrence/$10,000 Aggregate Limit Property in your care custody and control
Premium:
$1000.00* Minimum Premium (Based on $18.00 per $1,000 in Sales)
$ 150.00 Broker Fee (Fully earned at Inception)
$ 100.00 Service Fee (Fully Earned at Inception)
Appropriate State Taxes and Fees
*Annual Premium in Excess of $2,499 is subject to a phone or physical audit. A self-audit may be requested on premiums more than $1,000 but less than $2,500.
Optional Coverages:
Sub-Contractor Liability (Rate: $8.57 per $1,000 of cost subject to $100 minimum)
Sub-Contractor Liability
Additional Insurred's ($100 each flat charge) No. of Additional Insured's: (Provde Information -name/address)
Remarks