You can obtain a quote bY providing the information in Section i - inStant quote below, Subject to the remainder provided prior to binding.
HBP 12/10
page 1 of 3
Home Based Business Application All States
I. INSTANT QUOTE INFORMATION
Instant Quote is only available for accounts with no losses in the past three years. If there is loss history, please complete the entire application.
Applicant’s name: __________________________________________________________________________________________________________
Location address: __________________________________________________________________________________ q Same as mailing address
City: ______________________________________________________ State: ______________________ Zip: ________________________
Description of Operations:
Business personal property limit $________________________________
Business income & extra expense limit $__________________________
OPTIONAL COVERAGES:
q Money & Securities (On/Off Premises) Money & Securities Limit
q$1,000/$1,000 q $2,000/$1,000 q$3,000/$1,000
q$4,000/$1,000 q $5,000/$2,000 q$7,500/$2,000
q$10,000/$5,000
Liability Section
Limit: q $300,000/$600,000 q $500,000/$1,000,000 q $1,000,000/$2,000,000
Exposure basis: your business gross annual receipts _________________
LOSS INFORMATION FOR THE PAST 3 YEARS
q None, or provide detail below.
Year Status Incurred Description
_______ Open/Closed $ ______________ _____________________________________________________________________________
_______ Open/Closed $ ______________ _____________________________________________________________________________
_______ Open/Closed $ ______________ _____________________________________________________________________________
II. Additional Interests (AI = Additional Insured, LP = Loss Payee, M = Mortgagee)
III. ELIGIBILITY CRITERIA
1. No business related claim greater than $25,000 in the past three years. q True q False
2. No more than two claims related to your business in the past three years. q True q False
3. No past, pending or planned foreclosures, bankruptcies, tax or credit lines against the applicant within five years. q True q False
4. Coverage has not been cancelled or non-renewed in the last three years (not applicable in Missouri) q True q False
If “False,” advise reason ________________________________________________________________________________________________
5. The business is operated out of your primary residence and you carry personal liability coverage. q True q False
6. No packaging or repackaging of any food or personal care products to be sold under your own label. q True q False
7. The applicant does not operate any other business or any other part of this business at a different location. q True q False
If “False,” explain ______________________________________________________________________________________________________
8. No involvement in the sale or manufacturing of explosives, chemicals, propellants, petroleum
or flammable liquids. q True q False
9. No installation of any products, excluding the installation of computer systems, office equipment, security
devices, or interior window treatments. q True q False
10. The applicant does not employ more than one person in the business. q True q False
11. The applicant does not perform any of the following services: body massage, hair straightening, tanning,
ear or body piercing, microdermabrasion, acid peels, hair replacement, hydrotherapy/saunas,
hair removal, ear candling, tattooing, body waxing. q True q False
12. No applicant or member of the household has been convicted of a felony. q True q False
Name Relationship/Interest Address City, State, Zip AI LP M
q q q
q q q
q q q
USLI.COM
888-523-5545
13. During the past five years no claim has been made or suit has been brought against the applicant, its
predecessor(s) in business, or any of its present or former owners, partners, officers, directors, employees
or independent contractors. q True q False
If “False,” explain ______________________________________________________________________________________________________
14. No owner, partner, officer, director, employee or independent contractor is aware of a circumstance,
allegation, contention, or incident which may result in a claim being made against the applicant, its
predecessor(s) in business, or any of its present or former partners, owners, officers, directors, employees
or independent contractors. q True q False
If “False,” explain ______________________________________________________________________________________________________
IV. CLASS SPECIFIC QUESTIONS q Not Applicable
1. Teacher/Tutor
You do not provide instruction for sports, physical education, industrial arts or martial arts. q True q False
2. Barber or beautician
The business does not have more than one chair in operation. q True q False
3. Crafts or handicrafts, candle sales or gift shops
The applicant is not involved in the making, sale or distribution of homemade candles. q True q False
4. Financial planner, tax preparer, bookkeeping service and accountants
The applicant does not have discretionary trading authority and/or access to customer funds. q True q False
5. Jewelry (Costume)
The applicant is not involved in the sale or distribution of fine jewelry (gold, silver, precious stones, etc.). q True q False
6. Household products
The applicant is not involved in the sale or distribution of hardware items, pet supplies or
floatation devices for bathtubs/pools or cleaning supplies. q True q False
7. Interior decorating
The applicant is not involved in designing renovations or structural changes to the building or
in the installation of art work or staging homes. q True q False
8. Ladies’/Girls’ and mens’/boys’ clothing accessories
The applicant is not involved in the manufacture distribution or sale of infant clothing. q True q False
9. Travel agents
The applicant is not involved in the organization or guiding of tours. q True q False
10. Personal fitness trainer
The applicant does not provide instruction for sports, physical education or martial arts. q True q False
V. ADDITIONAL APPLICANT INFORMATION
Web site address for business?
________________________________________________
What year did the business start?
_______________________________________________
Form of business: q Individual q Corporation q Partnership q LLC q Other ___________________________
Applicant’s mailing address: ____________________________________________________ (if different than the location address above)
City: ______________________________________________________ State: ______________________ Zip: ________________________
E-mail address of primary contact: _____________________________________________ Phone: ____________________________________
Inspection contact name: _______________________________________ Telephone/E-mail address: ___________________________________
Audit contact name: ____________________________________________ Telephone/E-mail address: ___________________________________
For Texas and New Jersey residents only:
County name: _________________________________________________
Construction (Texas Only): q Frame q Masonry
HBP 12/10 - United States Liability Insurance Group
page 2 of 3
Virginia Notice: Statements in the application shall be deemed the insured’s representations. A statement made in the application or in any
affidavit made before or after a loss under the policy will not be deemed material or invalidate coverage unless it is clearly proven that such
statement was material to the risk when assumed and was untrue.
Minnesota Notice: The clause “and/or authorization or agreement to bind the insurance.” is replaced with “Authorization or agreement to bind
the insurance may be withdrawn or modified based on changes to the information contained in this application prior to the effective date of
the insurance applied for that may render inaccurate, untrue or incomplete any statement made with a minimum of 10 days notice given to the
insured prior to the effective date of cancellation when the contract has been in effect for less than 90 days or is being canceled for
nonpayment of premium.”
Colorado Fraud Statement: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company
for the purpose of defrauding or attempting to defraud the company. Penalties may include imprisonment, fines, denial of insurance, and civil
damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading facts or
information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant with regard to a
settlement or award payable from insurance proceeds shall be reported to the Colorado division of insurance within the department of
regulatory agencies.
District of Columbia Fraud Statement: WARNING: It is a crime to provide false or misleading information to an insurer for the purpose of
defrauding the insurer or any other person. Penalties include imprisonment and/or fines. In addition, an insurer may deny insurance benefits if
false information materially related to a claim was provided by the applicant.
Florida Fraud Statement: You are agreeing to place coverage in the surplus lines market. Superior coverage may be available in the
admitted market and at a lesser cost. Persons insured by surplus lines carriers are not protected under the Florida Insurance Guaranty Act with
respect to any right of recovery for the obligation of an insolvent unlicensed insurer.
Kentucky Fraud Statement: Any person who knowingly and with intent to defraud any insurance company or other person files an application
for insurance containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material
thereto commits a fraudulent insurance act, which is a crime.
Maine and Washington Fraud Statement: It is a crime to knowingly provide false, incomplete or misleading information to an insurance
company for the purpose of defrauding the company. Penalties may include imprisonment, fines or a denial of insurance benefits.
New Jersey Fraud Statement: Any person who includes any false or misleading information on an application for an insurance policy is
subject to criminal and civil penalties.
New York Fraud Statement: Any person who knowingly and with intent to defraud any insurance company or other person files an application
for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading, information
concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to
exceed five thousand dollars and the stated value of the claim for each such violation.
Ohio Fraud Statement: Any person who, with intent to defraud or knowing that he is facilitating a fraud against an insurer, submits an
application or files a claim containing a false or deceptive statement is guilty of insurance fraud.
Oklahoma Fraud Statement: WARNING: Any person who knowingly, and with intent to injure, defraud or deceive any insurer, makes any
claim for the proceeds of an insurance policy containing any false, incomplete or misleading information is guilty of a felony.
Pennsylvania Fraud Statement: Any person who knowingly and with intent to defraud any insurance company or other person files an
application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information
concerning any fact material thereto commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil
penalties.
Tennessee and Virginia Fraud Statement: It is a crime to knowingly provide false, incomplete or misleading information to an insurance
company for the purpose of defrauding the company. Penalties include imprisonment, fines and denial of insurance benefits.
Fraud Statement (All Other States): Any person who knowingly presents a false or fraudulent claim for
payment of a loss or benefit or knowingly presents false information in an application for insurance may be
guilty of a crime and may be subject to fines and confinement in prison.
Applicant’s signature: ____________________________________________ Title: _________________________ Date: _________________________
If your state requires that we have information regarding your authorized retail agent or broker, please provide below.
Retail agency name: _______________________________________________________________________ License #: ___________________________
Main agency phone number: ____________________________________________________________________________________________________
Agency mailing address: _________________________________________________________________________________________________________
City: ________________________________________ State: __________________ Zip code: ___________________________
HBP 12/10 - United States Liability Insurance Group
page 3 of 3
click to sign
signature
click to edit