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Business Application

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General Information

Name

Contact First Name Contact Last Name

Named Insured

DBA

Other Entities

Effective Date

Est. Close Date

Type of Entity

FEIN

Date Business Started

Years of Experience

Website

Mailing Address

Street Address Address Line 2 City State/Prov./Region ZIP/Postal Country

Physical Address

Street Address Address Line 2 City State/Prov./Region ZIP/Postal Country

Contact Information

Main Contact

First Name Last Name

Title

Cell Phone

Office Phone

Other Contact Information

Other Contact

First Name Last Name

Title

Cell Phone

Office Phone

Full Description of Operations

Lines of Business/Target Pricing

Premium

Type

Carrier

Expiration Date

Expiring

Target

Type

Carrier

Expiration Date

Expiring

Premium

Type

Carrier

Expiration Date

Expiring

Package

Type

Carrier

Expiration Date

Expiring

Workers Comp

Type

Carrier

Expiration Date

Expiring

Auto

Type

Carrier

Expiration Date

Expiring

Umbrella

Type

Carrier

Expiration Date

Expiring

GL Only

Type

Carrier

Expiration Date

Expiring

Property Only

Type

Carrier

Expiration Date

Expiring

Loss Information

Lines of Business

Date

Details Amt.

Paid

Additional Information

Is the applicant a subsidiary of another entity?

Yes

Does the applicant have any subsidiaries?

Yes

Is there a Formal Safety Program in operation?

Yes

If yes, please describe

Any policies declined, canceled, or non-renewed in the past 3 years?

Yes

During the last five years, have you been indicted or convicted of any degree of fraud, bribery or arson in connection with this or any other property?

Yes

Any past losses related to sexual abuse or molestation allegations?

Yes

Does the applicant install, service, or demonstrate products?

Yes

Foreign products sold, distributed, used as components

Yes

Any Exposure to radioactive/nuclear materials?

Yes

Commercial Property

Coverage Limits & Building Information

Location 1

Building Limit:

Building Valuation (RCV; ACV):

Business Personal Property Limit:

Improvements & Betterments:

Business Income:

Construction Type (Frame, Masonry, Non-combustible, Fire Resistive):

Roof Type (Composition, Metal, Roll Roofing, Etc.):

Year Built:

Total Square Foot of Building:

Square Foot Occupied by Insured:

BUILDING IMPROVEMENTS

Roof

Year

Partial/Complete

Partial

Complete

Partial/Complete

Partial

Complete

Plumbing

Year

Wiring

Year

Partial/Complete

Partial

Complete

Heating-A/C

Year

Partial/Complete

Partial

Complete

Additional Building Information

Landlord/Loss Payee, Mortgagee or Additional Insured

Building Sprinklered; %

Central Monitored Burglar and

Fire Alarm

County/Public Protection Class

General Liability - Exposures

State

Code

Description

Exposure Estimate

Exposure Basis (Sales/Payroll/Area)

General Aggregate

Each Occurrence

Products Aggregate

Personal/Adv Injuries

Fire Damage

Medical Payments

Subcontracted Cost for Insured Subs

How much of the work is subcontracted

Sub-Contracted Cost for Uninsured Subs

Blanket Additional Insured

Yes

Blanket Waiver of Subrogation

Yes

Blanket Waiver of Subrogation

Yes

Primary and Noncontributory when required

Yes

Completed Operations (when required)

Yes

Liquor Liability?

Yes

If yes, Limit: Retroactive Date:

Employee Benefits Liability?

Yes

If yes, Limit: Retroactive Date:

Data Breach/Cyber Liability?

Yes

If yes, Limit: Retroactive Date:

Notes:

Professional Liability?

Yes

Sales

Payroll

Sales

Payroll

Sales

Payroll

Sales

Payroll

Year

Sales

Payroll

Business Automobile

Combined Single Limits

Desired Limits

Uninsured/Underinsured Motorist

Desired Limits

Medical Payments

Desired Limits

Comp/Collision Deductible

Desired Limits

Hired and Non-Owned Limits

Desired Limits

Additional Insured?

Yes

Desired Limits

Waiver of Subrogation?

Yes

Desired Limits

Vehicle Schedule

Vehicle 1

Year

Make

Model

VIN

Model

Value

Garaging Zip

Radius of Operations

50 miles

100 miles

200 miles

Vehicle 2

Year

Make

Model

VIN

Value

Garaging Zip

Radius of Operations

50 miles

100 miles

200 miles

Vehicle 3

Year

Make

Model

VIN

Year

Value

Garaging Zip

Radius of Operations

50 miles

100 miles

200 miles

Vehicle 4

Year

Make

Model

VIN

Value

Garaging Zip

Radius of Operations

50 miles

100 miles

200 miles

Vehicle 5

Year

Make

Model

VIN

Value

Garaging Zip

Radius of Operations

50 miles

100 miles

200 miles

Driver Schedule

Driver 1

Name

First Name Last Name

Date of Birth

License #

Marital Status

Married

Not Married

Violations

Driver 2

Name

First Name Last Name

Date Of Birth

License #

Marital Status

Married

Not Married

Violations

Name

First Name Last Name

Driver 3

Name

First Name Last Name

Date Of Birth

License #

Marital Status

Married

Not Married

Violations

Driver 4

Name

First Name Last Name

Date Of Birth

License #

Marital Status

Married

Not Married

Violations

Driver 5

Name

First Name Last Name

Date Of Birth

License #

Marital Status

Married

Not Married

Violations

Workers Compensation

State

Class

Description

# Employees

Payroll Estimate

Officers Included/Excluded?

Name

First Name Last Name

Date of Birth

Title

Duties

Payroll

Ownership %

Experience MOD

Effective Year

Employer Liability Limits

100/100/100

500/500/500

1000/1000/1000

Blanket Waiver of Subrogation

Foreign Coverage

Stop Gap Coverage

Umbrella / Excess

Desired Limit

Self-Insured Retention

Underlying Policies

Effective Date

Carrier

Line of Business

Limits

The Independent Agency Advantage

We are insurance advisors.

We want you to make an informed decision on your insurance coverage. Through education, we work to simplify the process so you can make an informed decision based on your needs.

We offer a wide variety of insurance solutions.

Your insurance needs are unique, your insurance coverage should be too. We help you find insurance solutions by offering a wide variety of coverage options.

We are by your side every step of the way.

You’re never on your own when it comes to your insurance. We’re here for you and work with the insurance company on your behalf.

See All the Reasons

Read Our Reviews

“While it took other insurance brokers days to get back to me with quotes, it took them 20 minutes and their quote beat everyone else in every regard.”

– Katelyn H.

“Worked with me to find a good rate, not pushy. Really happy with the transparency of the agent—seems like good people.”

– Katherine A.

“Cash & Forbes gave me the best rate, I had a quote within a few hours, and staff was nice while gathering my information!”

– Sherry C.

Read Our Reviews

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Houston, TX Office

13501 Katy Freeway, Suite 1875
Houston, TX 77079

Liberty Hill, TX Office

9017 W. State Highway 29, STE 207
Liberty Hill, TX 78642

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At Cash & Forbes Insurance Group, our mission is to help you and your family find insurance that works for your unique needs. We do this all while treating you like we would want to be treated—with the facts, honesty, and quick responses.

We are licensed in Texas.

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