Forms & Applications

New Submissions Form

​For all submissions (other than monoline Workers' Comp), please complete and include a​ New Business Submissions Summary.

​Supplemental Applications
Some applications are Carrier Specific. Please contact underwriting before proceeding.

Ambulance Supplemental Application
Appliance & Furniture Delivery Trucking Supplemental Application
Assisted Living Workers' Compensation Supplemental Application
Automobile Physical Damage Application - Lloyd's of London
Auto Service and Dealership Supplemental Application
BOP Convenience Store/Gas Station Supplemental Application
Business Commercial Auto Supplemental Questionnaire 
Box Trucks/Cargo Vans Transportation Application 
Cannabis Workers' Compensation Supplemental Application
Child Care Supplemental Application
Commercial Auto Supplemental Application
Commercial Auto Supplemental Application - Cannabis Delivery (ODNC)
Commercial Auto Supplemental Application - Cannabis Delivery (LBA) 
Commercial Auto Supplemental Application - Light Business Auto (LBA)
Commercial Auto Supplemental Application - On-Demand Delivery Company (ODNC) 
Commercial Auto Physical Damage Application
​Contractor General Liability Application
Contractors Workers' Compensation Supplemental Application
Demolition Supplemental Application
Delivery Truck Application
Driver Schedule Supplemental
Dump Trucks Supplemental Application
Event Cancellation Application
Farm & Harvesting Workers' Compensation Questionnaire
Fuel Oil & Propane Transportation Supplemental Application
Furniture & Appliance Delivery Trucking Supplemental Application
Habitational Supplemental Questionnaire
Hired & Non-Owned Auto Supplemental Application
Health Care Workers' Compensation Supplemental Application
Hospital Fleet Supplemental Application
Inland Marine Supplemental Application
Janitorial Workers' Compensation Supplemental Application
Lawn Care Supplemental Application
Lawyers Professional Liability Application
Limousine Supplemental Application
Limos, Buses, Shuttles & Taxis Transportation Application
Long-Haul Trucking Supplemental Application
Miscellaneous Medical Malpractice Application
Miscellaneous Medical Professional Liability and General Liability Insurance Application
New Furniture & Appliance Delivery Trucking Supplemental Application 
Non-Emergency & Emergency Medical Transportation Application
Non-Emergency Medical Transportation Application
Non-Emergency Medical Transportation Supplemental Application 
Paratransit Supplement Application (Auto Only)
Paratransit Supplement Application (General Liability & Professional Liability)
Pest Control Supplemental Application
Prize Indemnity Application
Propane & Fuel Oil Transportation Supplemental Application
Restaurant/Bar/Tavern Supplemental Application
Security Guard General Liability Application
Security Guard Supplemental Application
School Bus Supplemental Application
Shooting Sports General Liability & Property Supplemental Application
Shooting Sports Workers' Compensation Supplemental Application
Snow and Ice Removal Contractors Supplemental Application
Special Event Liability Application
Specialty Auto Supplemental Questionnaire 
Taxi Supplemental Application
Transportation Application (for Box Trucks/Cargo Vans and Tractor Trailers)
Transportation Application (for Limos, Buses, Shuttles & Taxis)
Transportation Workers' Compensation Supplemental Application
Trucking Application
Trucking Supplemental Application
​Vehicle Schedule Supplemental
Waste Haulers Supplemental Application
Weather Insurance Application
Winery Supplemental Application
​

Lines of Business

BOP
BOP Commercial Property and Casualty
​BOP Convenience Store/Gas Station Supplemental Application (if applicable)

 

Commercial Auto
Some applications are Carrier Specific. Please contact underwriting before proceeding.

Fillable Applications
Ambulance Supplemental Application
Business Commercial Auto Supplemental Questionnaire 
Commercial Auto Supplemental Application
Commercial Auto Supplemental Application - Cannabis Delivery (ODNC)
Commercial Auto Supplemental Application - Cannabis Delivery (LBA) 
Commercial Auto Supplemental Application - Light Business Auto (LBA)
Commercial Auto Supplemental Application - On-Demand Delivery Company (ODNC) ​
Commercial Auto Physical Damage Application
Dump Trucks Supplemental Application
Fuel Oil & Propane Transportation Supplemental Application
Furniture & Appliance Delivery Trucking Supplemental Application
Hired & Non-Owned Auto Supplemental
Hospital Fleet Supplemental Application
Limousine Supplemental Application
Miscellaneous Medical Malpractice Application
Non-Emergency & Emergency Medical Transportation Application
Non-Emergency Medical Transportation Supplemental Application 
Paratransit Supplement Application (Auto Only)
Paratransit Supplement Application (General Liability & Professional Liability)
School Bus Supplemental Application
Specialty Auto Supplemental Questionnaire
Taxi Supplemental Application 
Transportation Workers' Compensation Supplemental Application
Trucking Application
​Waste Haulers Supplemental Application

Excel File Applications
Non-Emergency Medical Transportation Application
Transportation Application (for Box Trucks/Cargo Vans and Tractor Trailers) 
Transportation Application (for Limos, Buses, Shuttles & Taxis)
Driver Schedule Supplemental
Vehicle Schedule Supplemental
​​

Inland Marine/Builders' Risk
Inland Marine Supplemental Application


Insurance Agents & Brokers Professional Liability
Insurance Agents E&O Application


Lawyers' Professional Liability
Lawyers Professional Liability Application


Professional Liability
Miscellaneous Medical Professional Liability and General Liability Insurance Application


Snow Plow Liability
Snow and Ice Removal Contractors Supplemental Application

​
​Workers’ Compensation
ERM 14 Form
AK Officer Exclusion Form
AL Member Officer Exclusion Form
AZ Employee Exclusion Form
CO Member Officer Exclusion Form
CT Member Officer Exclusion Form
CT Partnership Exclusion Form
CT Sole Proprietor Election Form
DE Member Officer Exclusion Form
FL Inclusion Form
FL Officer Exclusion Form
FL Sole Proprietor Partner Inclusion Form - Non-construction
GA Election or Rejection Form​
IA Officer Exclusion Form
IA Sole Proprietor Member Partner Exclusion Form
ID Inclusion Form
IN Election or Rejection Form
KS Employee Cancellation of Exclusion Form
KS Employer Exclusion Form
KS Sole Proprietor Partner Member Cancellation of Exclusion
KS Sole Proprietor Partner Member Inclusion Form
MA Officer Exclusion Form
MA Workers’ Comp Assigned Risk Pool Application
MD Officer Exclusion Form
MD Sole Proprietor Partner Inclusion Form
ME Exclusion Form
MO Member Exclusion Form
NH Rejection of Coverage
NJ Exclusion or Inclusion Form
NM Officer Cancellation of Exclusion Form
NM Officer Exclusion Form
NM Sole Proprietor Exclusion Form
NV Sole Proprietor Exclusion Form
NY Cancellation of Exclusion Form - Non Profit
NY Cancellation of Exclusion Form
NY Exclusion Form - Non-profit
NY Exclusion Form
PA Application for Officer Exclusion Form
PA Construction Premium Credit
PA Officer Exclusion Form
RI Independent Contractor Designation Notice
RI Officer Inclusion Form
RI Withdrawal as Independent Contractor Form
SC Officer Exclusion Form
TN Officer Cancellation of Exclusion Form
TN Officer Exclusion Form
TN Sole Proprietor Partner Member Cancellation of Inclusion Form
TN Sole Proprietor Partner Member Inclusion Form
VA Officer Cancellation of Exclusion Form
VA Officer Exclusion Form
VT Officer Exclusion Form
WV Exclusion Form

Carrier Workers’ Compensation Exclusion Forms
AIG - CA Exclusion Form
AmTrust - CA Exclusion Form
Employers - CA Exclusion Form
Falls Lake - CA Exclusion Form
Markel - CA Exclusion Form
National Liability & Fire - CA Exclusion Form
NorGUARD - CA Exclusion Form
Republic Underwriters - CA Exclusion Form
StarStone - CA Exclusion Form
Statefund - CA Exclusion Form
Travelers - CA Exclusion Form