EXPOSURE REVIEW

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Business Name (Click the "+" Icon to add any DBA's)

Named Insured on Policy*

Mailing Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Is Your Physical Address different than your Mailing Address?*

Yes

Physical Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Primary Contact*

First Last

Email*

Phone*

Fax

FEIN Number*

Entity Type*

Year Founded*

Ownership Information

Full Name

Title

% of Ownership

Description of Operations*

What Coverages Do You Need?

GENERAL LIABILITY*

YES

Estimated Annual Gross Sales

Subcontractor Cost

Payroll Information

Job description

Estimated Annual Payroll

PROPERTY*

Building or Contents

YES

Location Name*

Ex: Location 1

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Occupancy*

Building Limit*

Contents Limit*

Deductible*

Year Built*

Square Footage*

Occupied Square Footage*

Mortgagee*

Do you need additional properties covered?*

Yes

Location Name*

Ex: Location 2

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Building Limit*

Contents Limit*

Deductible*

Occupancy*

Occupied Square Footage*

Year Built*

Square Footage*

Mortgagee*

BUSINESS AUTO*

Yes

Attach copy of Vehicle Schedule or List Below

Drop files here or

Max. file size: 300 MB.

Vehicle Schedule

Year

Make

Model

VIN #

Cost New

Current Value

Select All That Apply*

MVR Verification

Driver Training

Vehicle Maintenance Program

Personal Use Policy

Hired / Non-Owned Auto Exposure

Specialized Equipment

Drug Screening

Defensive Driving

Transport Hazmat

Transport Employees

Transport Public Passengers

Extra Wide Loads

NONE OF THE ABOVE

Drivers*

Employee Name

Date of Birth (00/00/0000)

Drivers License Number

State

EQUIPMENT*

Yes

Attach Copy of Equipment Schedule or List Below

Max. file size: 300 MB.

Equipment Schedule*

Year

Manufacturer

Model

Description

Serial Number

Value/Limit

WORKERS' COMPENSATION*

Yes

Policy Limit

List

Class Code

Description

Number of Employees

Annual Payroll

Other Coverages

Umbrella/Excess Liability

Prior Carrier and Loss/Claims History Notes:

Attach Current Policy Information

Max. file size: 300 MB.

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4300 FM 2351
Friendswood, TX 77546

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Who We Are
Media
Our Services
Client Tools
Pay Bill
Report Claim

Contact Us
Call 281-204-8770

Visit Highpoint Insurance Group on Twitter
Visit Highpoint Insurance Group on Facebook
Visit Highpoint Insurance Group on Linkedin
Visit Highpoint Insurance Group on Youtube
Visit Highpoint Insurance Group on Phone
Visit Highpoint Insurance Group on Email