Step 1 of 29 3% General Company InformationBusiness Name(Required)Industry(Required)Please choose your industryChurchChildcareFuneral HomeAutomotive ShopContractorRestaurantOtherBusiness Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Business WebsiteFederal Employer Identification Number (FEIN)Primary Contact Name(Required)Primary Contact Phone(Required)Primary Contact Email(Required) Current Insurance Provider InformationName of Current Insurance ProviderPolicy NumberPolicy Expiration Date MM slash DD slash YYYY Policy Premium Church InformationDenominationYear FoundedEstimated Annual RevenueDo you have more than 1 location?Please choose one...YesNo Childcare InformationYear FoundedEstimated Annual RevenueDo you have more than 1 location?Please choose one...YesNo Funeral Home InformationYear FoundedEstimated Annual RevenueDo you have more than 1 location?Please choose one...YesNo Auto Shop InformationYear FoundedEstimated Annual RevenueDo you have more than 1 location?Please choose one...YesNo Contractor InformationYear FoundedEstimated Annual RevenueNumber of EmployeesDo you have more than 1 location?Please choose one...YesNo Restaurant InformationYear FoundedEstimated Annual RevenueNumber of EmployeesDo you have more than 1 location?Please choose one...YesNo Property InformationDo you own your building?Please choose one...YesNoName of BuildingProperty Address(Required) Same as Business Address above Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Year BuiltType of ConstructionPlease choose one...Wood FrameSteel FrameMetal BuildingBrickSquare FeetDoes property have an Alarm?Please choose one...YesNoDoes property have Smoke Detectors?Please choose one...YesNoDoes property have Emergency Exit Lighting?Please choose one...YesNoDoes property have Sprinkler System?Please choose one...YesNoDoes property have Commercial-Grade Kitchen?Please choose one...YesNoEstimated Value of Playground EquipmentEstimated Value of Owned Kitchen EquipmentEstimated Value of FurnitureEstimated Value of ToolsAre tools and equipment properly stored and secured when at your place of business?Please choose one...YesNoAre tools, equipment or materials left overnight at job sites?Please choose one...YesNoAdd a second building?Please choose one...NoYes Building 2 InformationName of BuildingProperty Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Year BuiltType of ConstructionPlease choose one...Wood FrameSteel FrameMetal BuildingBrickSquare FeetDoes property have an Alarm?Please choose one...YesNoDoes property have Smoke Detectors?Please choose one...YesNoDoes property have Emergency Exit Lighting?Please choose one...YesNoDoes property have Sprinkler System?Please choose one...YesNoDoes property have Commercial-Grade Kitchen?Please choose one...YesNoEstimated Value of Playground EquipmentEstimated Value of Owned Kitchen EquipmentEstimated Value of FurnitureEstimated Value of ToolsAre tools and equipment properly stored and secured when at your place of business?Please choose one...YesNoAdd a third building?Please choose one...NoYes Building 3 InformationName of BuildingProperty Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Year BuiltType of ConstructionPlease choose one...Wood FrameSteel FrameMetal BuildingBrickSquare FeetDoes property have an Alarm?Please choose one...YesNoDoes property have Smoke Detectors?Please choose one...YesNoDoes property have Emergency Exit Lighting?Please choose one...YesNoDoes property have Sprinkler System?Please choose one...YesNoDoes property have Commercial-Grade Kitchen?Please choose one...YesNoEstimated Value of Playground EquipmentEstimated Value of Owned Kitchen EquipmentEstimated Value of FurnitureEstimated Value of ToolsAre tools and equipment properly stored and secured when at your place of business?Please choose one...YesNoAdd a fourth building?Please choose one...YesNo Building 4 InformationName of BuildingProperty Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Year BuiltType of ConstructionPlease choose one...Wood FrameSteel FrameMetal BuildingBrickSquare FeetDoes property have an Alarm?Please choose one...YesNoDoes property have Smoke Detectors?Please choose one...YesNoDoes property have Emergency Exit Lighting?Please choose one...YesNoDoes property have Sprinkler System?Please choose one...YesNoDoes property have Commercial-Grade Kitchen?Please choose one...YesNoEstimated Value of Playground EquipmentEstimated Value of Owned Kitchen EquipmentEstimated Value of FurnitureEstimated Value of ToolsAre tools and equipment properly stored and secured when at your place of business?Please choose one...YesNoAdd a fifth building?Please choose one...YesNo Building 5 InformationName of BuildingProperty Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Year BuiltType of ConstructionPlease choose one...Wood FrameSteel FrameMetal BuildingBrickSquare FeetDoes property have an Alarm?Please choose one...YesNoDoes property have Smoke Detectors?Please choose one...YesNoDoes property have Emergency Exit Lighting?Please choose one...YesNoDoes property have Sprinkler System?Please choose one...YesNoDoes property have Commercial-Grade Kitchen?Please choose one...YesNoEstimated Value of Playground EquipmentEstimated Value of Owned Kitchen EquipmentEstimated Value of FurnitureEstimated Value of ToolsAre tools and equipment properly stored and secured when at your place of business?Please choose one...YesNo Church LiabilityAverage Weekly AttendanceNumber of Paid EmployeesIs there a youth group provided?Please choose one...YesNoHow many Students attend weekly?Is youth group taught by:Please choose one...VolunteerEmployeeAre all adults working with youth background checked?Please choose one...YesNoDo you have a written procedure for dealing with any accusations of sexual misconduct and physical abuse?*Please choose one...YesNoIs there a nursery available during house of worship activities?Please choose one...YesNoDo you own or have access to a playground?Please choose one...YesNoIs it fenced?Please choose one...YesNoIs there a Childcare Center?Please choose one...YesNoHow many children under 24 months?How many children 2 years to 3 years?How many children 3 years to 4 years?How many children 4 years to 5 years?How many after schoolers?Does the organization own any vans or buses?Please choose one...NoYes Childcare LiabilityTotal Number of StudentsNumber of Paid EmployeesAre all adults working with youth background checked?Please choose one...YesNoDo you have a written procedure for dealing with any accusations of sexual misconduct and physical abuse?*Please choose one...YesNoDo you own or have access to a playground?Please choose one...YesNoIs it fenced?Please choose one...YesNoHow many children under 24 months?How many children 2 years to 3 years?How many children 3 years to 4 years?How many children 4 years to 5 years?How many after schoolers?Do you provide Drop-in Services?Please choose one...YesNoIs food properly prepared, covered, stored, and served in accordance with applicable government requirements?Please choose one...YesNoAre immunization records updated annually?Please choose one...YesNoDo you require signed releases for emergency medical treatment?Please choose one...YesNoDo you require written instructions from the child’s physician for dispensing medication?Please choose one...YesNoDoes the business own any vans or buses?Please choose one...NoYes Funeral Home LiabilityNumber of EmployeesTotal Number of Services Held AnnuallyDoes the applicant own a cemetery?Please choose one...YesNoHow many acres is the cemetery?How many plots in the cemetery?Does the applicant operate a crematory?Please choose one...YesNoHow many years of experience does the Crematory Operator have?Do you handle/store credit card information of others?Please choose one...YesNoWhat are your hours of operation?Does the business own any vans or buses?Please choose one...NoYes Auto Shop LiabilityTotal Number of Service BaysDo you have any mobile operations?Please choose one...YesNoDo you have a salvage lot?Please choose one...YesNoDo you repossess autos?Please choose one...YesNoDo you own a tow truck?Please choose one...YesNoDo you own frame straightening equipment?Please choose one...YesNoAre customers allowed in service area?Please choose one...YesNoDo you install or modify trailer hitches?Please choose one...YesNoDo you recap tires?Please choose one...YesNoDo you have surveillance cameras?Please choose one...YesNoAre customer's autos secured when unattended?Please choose one...YesNoAre customer's keys secured with restricted access?Please choose one...YesNoWhat is the average value of customer's cars on the premises?What is the average number of vehicles stored inside building?What is the average number of vehicles stored outside building?Do you test drive customers' autos?Please choose one...YesNoDo you have smoke detectors in service bays?Please choose one...YesNoDo you paint autos?Please choose one...YesNoIs all painting done in approved booths?Please choose one...YesNoDo you ever install used/salvage parts?Please choose one...YesNoPercentage of Overall Business from Tire SalesSelect Types of Vehicles Serviced Private Passenger/SUV/Lt Truck Vehicles with 10-25k GVW Watercraft (Boats, Jet Skis, etc.) Farm/Contractor Equipment Antique/Classic Cars Motorhomes/RV's High Performance Vehicles Other types of Recreational Auto Do you provide shuttle service?Please choose one...YesNoDo you provide loaner vehicles?Please choose one...YesNoDoes the shop own any automobiles, trucks, or vans?Please choose one...NoYes Contractor LiabilityType of Work Performed Commercial Industrial Residential Type of Residential Work New tract homes New custom homes Condos/Townhomes Apartments Existing Residential State(s) Work is Performed InPercentage of Work SubcontractedAre these subcontractors insured?Please choose one...YesNoAnnual Cost of SubcontractorsWhat type(s) of contracting do you do? HVAC Electrical Concrete Swimming Pool Service Plumbing Landscaping Roofing Pest Control Movers Other Type(s) of Electrical Work Electrical Machinery Installation, Service or Repair Electrical Power Lines High Voltage Work (over 480 Volts) Security Systems or Alarm Installation Installation of Transformers, Electrical Panels, or Electrical Motors Traffic Signal Work Underground Cable Work Type(s) of Concrete Work Commercial Foundations above 3 Stories Residential Foundations Street, Road or Alley Operations Tilt Work above 2 Stories Mix in Transit Operations Type(s) of HVAC Work Boiler Work Systems using LP Gas as an energy source Rooftop Units What's the highest floor level you access rooftop units on?Type(s) of Landscaping Work Fertilizer, Herbicide, Pesticide Spraying Outdoor Fireplaces Tree Trimming from the ground Tree Trimming from above the ground Tree Removal Hardscapes Pool Services Sprinkler System Installation/Repair What percentage of your business is lawn maintenance?What percentage of your business is landscape & design?Type(s) of Plumbing Work Interior Sprinkler System Installation Underground Sprinkler Installation Medical Gas Work Process Pipe Work Sewer Main Work Water Main Work Does the business own any automobile, trucks, or vans?Please choose one...NoYes Restaurant LiabilityType of Establishment Family-style Restaurant Fine Dining Fast Food Deli Bar Annual Food SalesAnnual Alcohol SalesAnnual Catering SalesWeekday Hours of OperationWeekend Hours of OperationTotal Number of EmployeesIs there Catering operations?Please choose one...YesNoPercentage of On-Premises CateringPercentage of Off-Premises CateringTotal Square Footage of BuildingIs this a BBQ restaurant?Please choose one...YesNoIs this a microbrewery?Please choose one...YesNoDo you rent space for banquets/parties?Please choose one...YesNoIs BYOB (bring your own beer) permitted?Please choose one...YesNoDo you have a Happy Hour?Please choose one...YesNoHow many hours per day?Please check any/all that apply to your establishment Live Entertainment Dance Floor Mechanical Devices Cover Charge Live Sports on Premises Playground Hatchet/Axe Throwing What is your typical clientele?Please choose one...Local ResidentsFamiliesRetirement CommunityCollege StudentsWhat is their median age?Please choose one...18-2526-3031-4041+In the past five years, has applicant been cited by the Liquor Control Commission?Please choose one...YesNoAre police records and background checks conducted on employees?Please choose one...YesNoNumber of Bouncers, Doormen, and/or Security PersonnelAre bouncers, doormen or security personnel independent contractors?Please choose one...YesNoDoes not applyDoes the restaurant own any automobiles, vans, or trucks?Please choose one...NoYes Auto InformationVehicle VIN NumberVehicle YearVehicle MakeVehicle ModelVehicle ValueIs this a 15-passenger vehicle?Please choose one...YesNoDoes this vehicle require Full Coverage?Please choose one...YesNoDriver's Name First Last Driver's Date of Birth MM slash DD slash YYYY Driver's License NumberState of Issuance AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Add a second driver?Please choose one...YesNoSecond Driver's Name First Last Second Driver's Date of Birth MM slash DD slash YYYY Second Driver's License NumberState of Issuance AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Add a second vehicle?Please choose one...YesNo Auto 2 InformationVehicle VIN NumberVehicle YearVehicle MakeVehicle ModelVehicle ValueIs this a 15-passenger vehicle?Please choose one...YesNoDoes this vehicle require Full Coverage?Please choose one...YesNoDriver's Name First Last Driver's Date of Birth MM slash DD slash YYYY Driver's License NumberState of Issuance AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Add a second driver?Please choose one...YesNoSecond Driver's Name First Last Second Driver's Date of Birth MM slash DD slash YYYY Second Driver's License NumberState of Issuance AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Add a third vehicle?Please choose one...YesNo Auto 3 InformationVehicle VIN NumberVehicle YearVehicle MakeVehicle ModelVehicle ValueIs this a 15-passenger vehicle?Please choose one...YesNoDoes this vehicle require Full Coverage?Please choose one...YesNoDriver's Name First Last Driver's Date of Birth MM slash DD slash YYYY Driver's License NumberState of Issuance AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Add a second driver?Please choose one...YesNoSecond Driver's Name First Last Second Driver's Date of Birth MM slash DD slash YYYY Second Driver's License NumberState of Issuance AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Add a fourth vehicle?Please choose one...YesNo Auto 4 InformationVehicle VIN NumberVehicle YearVehicle MakeVehicle ModelVehicle ValueIs this a 15-passenger vehicle?Please choose one...YesNoDoes this vehicle require Full Coverage?Please choose one...YesNoDriver's Name First Last Driver's Date of Birth MM slash DD slash YYYY Driver's License NumberState of Issuance AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Add a second driver?Please choose one...YesNoSecond Driver's Name First Last Second Driver's Date of Birth MM slash DD slash YYYY Second Driver's License NumberState of Issuance AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Add a fifth vehicle?Please choose one...YesNo Auto 5 InformationVehicle VIN NumberVehicle YearVehicle MakeVehicle ModelVehicle ValueIs this a 15-passenger vehicle?Please choose one...YesNoDoes this vehicle require Full Coverage?Please choose one...YesNoDriver's Name First Last Driver's Date of Birth MM slash DD slash YYYY Driver's License NumberState of Issuance AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Add a second driver?Please choose one...YesNoSecond Driver's Name First Last Second Driver's Date of Birth MM slash DD slash YYYY Second Driver's License NumberState of Issuance AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State Worker's Compensation / ChurchNumber of ClergyTotal Annual Payroll of all ClergyNumber of Office/Admin StaffTotal Annual Payroll of all Office/Admin StaffNumber of TeachersTotal Annual Payroll of all TeachersNumber of Maintenance/Janitorial EmployeesTotal Annual Payroll of all Maintenance/Janitorial Employees Worker's Compensation / ChildcareNumber of Office/Admin StaffTotal Annual Payroll of all Office/Admin StaffNumber of TeachersTotal Annual Payroll of all Teachers Worker's Compensation / Funeral HomeNumber of Office/Admin StaffTotal Annual Payroll of all Office/Admin StaffNumber of Funeral DirectorsTotal Annual Payroll of all Funeral DirectorsNumber of Funeral AssistantsTotal Annual Payroll of all Funeral AssistantsNumber of Office DriversTotal Annual Payroll of all Office DriversNumber of UndertakersTotal Annual Payroll of all UndertakersNumber of Grounds KeepersTotal Annual Payroll of all Grounds Keepers Worker's Compensation / Auto ShopNumber of Office/Admin StaffTotal Annual Payroll of all Office/Admin StaffNumber of Auto MechanicsTotal Annual Payroll of all Auto Mechanics Worker's Compensation / ContractorsNumber of Office/Admin StaffTotal Annual Payroll of all Office/Admin StaffNumber of TechniciansTotal Annual Payroll of all Technicians Worker's Compensation / RestaurantNumber of Office/Admin StaffTotal Annual Payroll of all Office/Admin StaffNumber of ServersTotal Annual Payroll of all ServersNumber of CooksTotal Annual Payroll of all CooksNumber of DishwashersTotal Annual Payroll of all Dishwashers Δ