Commercial Insurance Application

Complete the Business Information section in full, plus any coverage sections you would like quoted. Skip sections you do not need. Attach loss runs and any schedules noted.

To market your account effectively and avoid blocked/duplicate carrier submissions, we ask to serve as your exclusive broker. Return by email to service@archerinsgroup.com.

Works on any phone, tablet, or computer — no app needed. Type N/A where a field does not apply. Fields marked * are required.

Business Information

How soon do you need quotes? Due Date *

Desired Effective Date *

Legal Business Name *

DBA / Trade Name (if any)

Mailing Address *

City

State

ZIP

Physical location same as mailing address?

If no, address:

City

State

ZIP

Business Phone

Website

Social Media Handles

Business Owner / Decision Maker

Business Owner Name

Cell Phone

Additional Owner Name

Cell Phone

Primary Contact Name

Cell Phone

Title

Business Structure & Details

Other Entity Type (if not listed)

FEIN or SSN (optional)

Year Business Started

NAICS / SIC Code

Owner Years in Industry

Financial Information

Gross Sales – Last 12 Mo $

Projected Sales – Next 12 Mo $

Prior Year Annual Payroll $

Est. Annual Payroll (current yr) $

Total # Employees

Current Annual Premium – all lines requested $

Referral & Contact Preference

Referred By / How Did You Hear About Us?

Preferred Contact Method & Best Time

Business Operations

Provide a Detailed Description of ALL Business Operations

Include subcontracted work & occupational hazards

Do you use subcontractors?

% of Work Subbed Out

Annual Sub Cost $

Require certificates of insurance from all subs?

# of Additional Insureds

Additional Named Insureds

List below or attach a complete list (Excel or other format) of all additional insureds with addresses and description of work performed.

Coverages Requested

Commercial Insurance Coverages

Other Coverages

Employee Benefits & Life / Wealth (optional)

Other Benefits Coverages

Loss History

Attach 5-year currently-valued loss runs (request from your current agent/carrier — usually provided within 24 hours).

Have you had any losses / claims in the past 5 years?

List and explain any claims or losses (date, type, amount, status):

Documents to Submit

Starred items are critical for marketing your account

Property & General Liability

Property Schedule

Current Carrier:

Annual Premium $:

Expiration Date:

Property Schedule / SOV attached — must include ALL details requested below for each property (if attached, you may skip below)

Location 1

Location #

Bldg #

Address

Property valuation requested:

Bldg Replacement Cost $

Bldg Market Value $

Contents / BPP $

Business Income $ (12-mo)

Other property to insure (describe):

Value $:

Year Built

# of Stories

Square Feet

Distance to Hydrant

Nearest Fire Station

Construction Type

Roof Material

Roof Shape

Year Updated — Roof

Wiring

Plumbing

HVAC

Sprinklered:

Alarms:

Monitored:

Location 2 (Check if no additional locations)

Location #

Bldg #

Address

Property valuation requested:

Bldg Replacement Cost $

Bldg Market Value $

Contents / BPP $

Business Income $ (12-mo)

Other property to insure (describe):

Value $:

Year Built

# of Stories

Square Feet

Distance to Hydrant

Nearest Fire Station

Construction Type

Roof Material

Roof Shape

Year Updated — Roof

Wiring

Plumbing

HVAC

Sprinklered:

Alarms:

Monitored:

General Liability

Current Carrier:

Annual Premium $:

Expiration Date:

Per-Occurrence Limit:

Other Per-Occurrence Limit $

Aggregate Limit:

Other Aggregate Limit $

Estimated Annual Gross Sales and Payroll by Location

(attach a list if more locations)

Location 1 Sales $

Payroll $

Location 2 Sales $

Payroll $

Business Auto

Coverage

Current Carrier:

Annual Premium $:

Expiration Date:

Liability

Other Liability Limit $

Uninsured Motorist (UM)

Other UM Limit $

Underinsured Motorist (UIM)

Other UIM Limit $

Medical Payments

Other Medical Payments Limit $

PIP (if available)

Other PIP Limit $

Physical Damage Deductible

Other Physical Damage Deductible $

Hired Auto Liability

Other Hired Auto Liability $

Non-Owned Auto Liability

Other Non-Owned Liability $

Motor Truck Cargo (if requested) Limit $:

Deductible $:

Vehicle & Operation Details

Garaging Address (if different from mailing address):

Cities/Areas of Operation:

Radius (furthest one-way miles):

Any vehicles owned but not listed below?

# Power Units:

# Trailers:

Federal / State Filings?

Other Filing Type & #:

USDOT #:

MC #:

Do you haul hazardous materials?

Interstate or Intrastate?

Do you use vehicles for livery / transporting passengers (shuttle, rideshare)?

Are vehicles used for delivery or hauling goods for others?

Any equipment permanently attached to the vehicles?

Value of attached equipment $:

Describe what/all materials, goods, or commodities you haul or transport (if any):

Vehicle List

Complete if quoting auto, or attach your vehicle schedule

Vehicle 1

Year

Make

Model

VIN

Value $

Seats

Lienholder

Vehicle 2

Year

Make

Model

VIN

Value $

Seats

Lienholder

Vehicle 3

Year

Make

Model

VIN

Value $

Seats

Lienholder

Vehicle 4

Year

Make

Model

VIN

Value $

Seats

Lienholder

Vehicle 5

Year

Make

Model

VIN

Value $

Seats

Lienholder

Driver List

Complete, or attach your driver list + MVRs

Driver 1

Driver Name

Date of Birth

License #

State

Years Experience

Violations

CDL (Y/N)

Driver 2

Driver Name

Date of Birth

License #

State

Years Experience

Violations

CDL (Y/N)

Driver 3

Driver Name

Date of Birth

License #

State

Years Experience

Violations

CDL (Y/N)

Driver 4

Driver Name

Date of Birth

License #

State

Years Experience

Violations

CDL (Y/N)

Driver 5

Driver Name

Date of Birth

License #

State

Years Experience

Violations

CDL (Y/N)

Workers' Compensation

Current Carrier:

Annual Premium $:

Expiration Date:

Employers Liability Limits:

State(s) Where You Have Employees:

Current Exp. Mod (EMOD):

Include your current experience-modification worksheet if in business 3+ years (NCCI states: call 800-622-4123 for a free copy).

Owners / Officers with 5%+ Ownership

First row shown in grey is an example — type over it

Name

Date of Birth

Ownership %

Include/Exclude

Payroll Est. $

Name

Date of Birth

Ownership %

Include/Exclude

Payroll Est. $

Name

Date of Birth

Ownership %

Include/Exclude

Payroll Est. $

Name

Date of Birth

Ownership %

Include/Exclude

Payroll Est. $

Staff Payroll by Classification

All payroll estimates annual. First row is an example — type over it

Location #

What do these employees do?

# of Employees

Annual Payroll Est. $

Location #

What do these employees do?

# of Employees

Annual Payroll Est. $

Location #

What do these employees do?

# of Employees

Annual Payroll Est. $

Location #

What do these employees do?

# of Employees

Annual Payroll Est. $

Additional Comments / Explanations

Additional Comments or Explanations:

Authorization & Return

Broker of Record / Exclusive Representation Acknowledgment *
I authorize J. Archer Insurance Group to market my account and act as my exclusive broker for this submission. I understand duplicate submissions by other agents can cause carriers to block our access and delay or jeopardize the best available pricing.

Applicant Signature (type full name) *

Date *

Print Name & Title

Tap Submit to send your answers to our team, or Save / Print as PDF to keep a copy and email it to service@archerinsgroup.com. Questions? Call 281-501-8331.

What Happens Next

Your dedicated commercial risk advisor will review your submission and reach out within 1–2 business days to discuss your coverage needs and timeline.

Our team will work to secure competitive quotes from top-tier carriers while ensuring your business is properly protected across all requested lines.