Crescent Insurance

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Business Owners Insurance Application
+ Business Owners
Insurance Application

+ Miscellaneous Professional
Liability Application

+ Insurance Agents and
Brokers E & O Application

+ Supplemental Claim
Information Form

Business Owners Insurance Application

If you have any questions about our programs or wish to contact Crescent Insurance Services, please fill out and submit the following information.

Please note that your submission will not be received without the required field information completed.

Any quote proposals received in response to the ASSOCIATION PROGRAMS are simply preliminary and are subject to underwriting guidelines and state assigned rates.

= required

General Information
Business Name
Contact Person
If a member, enter Association/Member ID
Membership ID is not required to receive quotation. Please note that you must be an association member before coverage is bound.
Legal Entity
Mailing Address:
Address 1
Address 2
Location Address:
 Check box if location address is the same as mailing address.

Address 1

Address 2


Website URL
Phone Number
Fax Number
Do you want property coverage, liability coverage or both?
Liability Information
Detailed Business Description:
Desired Effective Date (mm/dd/yyyy)
Year Business Started
Number Years Experience
Total Annual Sales
Estimate Annual Payroll
Number of Employees)
Number of Stories
Year Building Was Constructed (home or office space)
Square Footage of Office Space (if you work out of your home, your answer should be the square footage of your home designated for the business only.)
Value of Home/Office Space
Home Construction
Update to Home or Office Space in Past 15 Years (please describe):
Property Coverage Information
For personal property and/or building.
 If you are not interested in any of the property coverages, please check here for "Not Interested".
Inside or Outside City/Town Limits
Number of Stories
Year Building Was Constructed
Building Construction
Protection Class/Fire District (1-10, 1 being the best, 10 being the worst)
Please fill in the replacement cost for any additional item that you would like to insure:
Replacement Cost of Building:
Replacement Cost of Furniture, Machinery, Equipment & Stock:
Replacement Cost of Any Tenant's Improvements or Betterments:
Replacement Cost of Computers & Other Hardware:
Replacement Cost of Software & Other Media:
Total Property Value
Personal Property Limit
Other Property Limit
Prior/Current Coverage Information
 If no prior/current coverage, please check here.
Current Insurance Carrier
Policy Expiration Date (mm/dd/yyyy)
Details on any claims in the past 4 years:
Additional Coverages Information
Stretch Coverage (additional coverage on equipment, materials, etc.)
Additional Comments

If no additional information is required, you will receive a response within 3 to 5 business days.


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