Fallaize Insurance Agency — Commercial Application Intake

Let's start your Application

This gathers everything needed for a Commercial Insurance Application — agency & policy details, applicant info, business operations, premises, prior carrier/loss history, and the standard underwriting disclosures & signatures. Takes about 15 minutes. Nothing here is submitted to a carrier — it just prepares the application for your agent to review.

Tip: have your prior policy declarations pages, loss runs, and payroll/revenue figures handy.

The policy dates and coverages being applied for.

Proposed Effective Date*

Proposed Expiration Date

Requested Lines Of Business*

Please select at least one line of business.

Applicant Information

Legal details about the business applying for coverage.

Legal Business Name*

DBA (if applicable)

Mailing Address

Street Address*

City*

State*

Zip*

Entity & Tax Details

Business Structure*

FEIN or SSN*

Date Business Started

Years In Business

NAICS Code (search by code or industry keyword)

SIC Code (search by code or industry keyword)

Business Operations

What the business does, who it sells to, and its size.

Description Of Operations*

0 words (10+ recommended)

Size & Classification

Estimated Annual Payroll $

Estimated Annual Gross Sales/Revenue $

Operational Risk Factors

% Of Work Subcontracted Out

% Of Work Performed Off-Premises (installation/repair away from the shop)

Any exposure to foreign-made products or foreign operations?

Yes No

Please provide a description of operations (10+ words).

Premises Information

Add every physical business location. Include the main location first.

Premises Description*

0 words (10+ recommended)

Please complete the address for at least the first location, and provide a premises description (10+ words).

Premises Details

Is there a security system?*

Yes No

Is the property fenced?*

Yes No

Is there a fire suppression system? (e.g. sprinkler system)*

Yes No

Is there a parking lot?*

Yes No

Is the property ADA compliant?*

Yes No

Age Of Roof (years)*

Any other betterments to the building?*

Please answer all of the premises questions above.

Coverage-Specific Details

Extra questions based on the lines of business requested in Step 1.

Business Auto (ACORD 127)

Radius Of Operation

DOT / MC Number (if applicable)

Do any vehicles haul hazardous materials?

Yes No

Any vehicles with a gross vehicle weight over 26,000 lbs?

Yes No

Vehicle Schedule

Driver Schedule

Driver's License Photos *

Upload a photo of each listed driver's license (front side) — clear and readable. Multiple photos are fine. Required unless you upload a spreadsheet or manually enter license info below.

🪪

Tap to upload driver's license photos

JPG, PNG, or PDF — you can add more than one

Or Upload A Spreadsheet Of Licenses (if not uploading photos)

Upload an Excel or CSV file listing your drivers' license info instead of individual photos.

📊

Tap to upload a license spreadsheet

XLSX, XLS, or CSV — you can add more than one

Vehicle Equipment List (optional)

Upload a spreadsheet or document listing equipment installed on each vehicle (lifts, racks, tanks, etc.).

🛠️

Tap to upload a vehicle equipment list

XLSX, XLS, CSV, or PDF — you can add more than one

Or Enter License Info Manually (if not uploading photos or a spreadsheet)

Please upload at least one driver's license photo, upload a license spreadsheet, or enter at least one license manually.

General Liability (ACORD 126)

Gross Sales $

Any products or completed operations exposure?

Yes No

Does the business use subcontractors without requiring certificates of insurance from them?

Yes No

Any professional services performed (design, consulting, advice-giving)?

Yes No

Any hired & non-owned auto exposure?

Yes No

Workers Compensation (ACORD 130)

States Of Operation

Experience Modification Factor (if known)

Any employees working outside the state(s) listed above?

Yes No

Any owners/officers to be excluded from coverage?

Yes No

Payroll Class Code Breakout

Break out estimated annual payroll by each applicable class code.

Total payroll across class codes: $0

Property (ACORD 140)

Requested Coverage

Building Business Personal Property Business Income

Construction Type

Protection Class (1-10, if known)

Roof Type

Roof Age (years)

Alarm Type

Is the building fully sprinklered?

Yes No

Distance To Nearest Fire Hydrant (ft)

Distance To Nearest Fire Station (miles)

Umbrella / Excess (ACORD 131)

Requested Umbrella/Excess Limit $

Underlying GL Limit $

Underlying Auto Liability Limit $

Underlying Employers Liability Limit $

Has any prior umbrella/excess policy been cancelled or non-renewed?

Yes No

Inland Marine

Scheduled Equipment

Is equipment regularly taken off-premises or transported to job sites?

Yes No

Prior Carrier & Loss History

Upload your prior policy documents and loss run history — no manual typing needed.

Prior Policy Declarations (past 3-5 years)

Upload the declarations page(s) from each prior/expiring policy — PDF or a clear photo/scan. Multiple files are fine.

📋

Tap to upload prior policy documents

PDF, JPG, or PNG — you can add more than one

No losses to report in the past 5 years

Loss Runs (past 5 years)*

Upload the official loss run document(s) from each prior carrier — PDF or a clear photo/scan. Multiple files are fine. Required unless you check "No losses to report" above.

📄

Tap to upload loss run files

PDF, JPG, or PNG — you can add more than one

Please upload at least one loss run file, or check "No losses to report" above.

General Disclosures

Standard underwriting questions. Answer Yes or No for each; explain any "Yes" answers.

Signature

Sign below to certify the information is accurate. The producer will countersign when the agency finalizes the application.

Applicant Printed Name*

Applicant Signature

Date

I certify that the information provided in this application is true, accurate, and complete to the best of my knowledge, and I authorize the agency to submit it to prospective carriers on my behalf.

Please complete your printed name, your signature, and check the certification box.

Review & Submit

Check everything below before submitting.

✅

Thanks — you're all set!

Your application data has been prepared. Choose how you'd like to send it to us: