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Uniserv Financial Services
Commercial and personal insurance in Riverside, CA
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Truckers
Garage Keepers
General Liability
Lessors Risk
Professional Liability
Property
Workers’ Compensation Insurance
Life
Accidental Death & Dismemberment
Buy-Sell Agreements
Final Expense
Indexed Universal Life
Key Man
Mortgage Protection
Universal Life
Whole Life
Employee Benefits
Accident
Cancer
Dental
Disability
Group Life
Medical
Terminal Illness
Vision
Individual
Auto
Homeowners
Landlord
Motorcycle
Renters
Affiliates
Become an Affiliate
Allied Residential Mortgage
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One Inland Empire
Uniko Media Group
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1
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3
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4
About the Business
5
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6
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7
General Liability Section
8
Workers Comp Section
9
Acknowledgment
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Company Contact Information
First
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Company Information
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Entity Type
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Industry
FEIN or Soc Sec #
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Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Premises Information
Premises Information
1 Location
2 Locations
3 Locations
4 Locations
5+ Locations
Location #1
Property Address
Street Address
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
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New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Interest
Owner
Tenant
# Full Time Employers
# Part Time Employers
Annual Revenues
Occupied Area
Open to Public Area
Total Building Area
Any Area Leased to Others?
Yes
No
Location #2
Property Address
Street Address
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Interest
Owner
Tenant
# Full Time Employers
# Part Time Employers
Annual Revenues
Occupied Area
Open to Public Area
Total Building Area
Any Area Leased to Others?
Yes
No
Location #3
Property Address
Street Address
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Interest
Owner
Tenant
# Full Time Employers
# Part Time Employers
Annual Revenues
Occupied Area
Open to Public Area
Total Building Area
Any Area Leased to Others?
Yes
No
Location #4
Property Address
Street Address
City
State
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Interest
Owner
Tenant
# Full Time Employers
# Part Time Employers
Annual Revenues
Occupied Area
Open to Public Area
Total Building Area
Any Area Leased to Others?
Yes
No
More than 4 Locations
Please provide information of all the properties
Property Address, Interest, Employment, Annual Revenues, Occupied Area, Open to Public Area, Total Building Area
Nature of Business
Nature of Business
Apartments
Condominiums
Contractor
Institutional
Manufacturing
Office
Restaurant
Retail
Service
Wholesale
Date Business Started
MM slash DD slash YYYY
Description of Primary Operations
Retail stores or service operations % of total sales:
Installation, Service or Repair Work
Off Premises Installation, Service or Repair Work
Description of Operations of Other Named Insureds
General Information
Explain All
"Yes"
Responses
1a. Is the applicant a subsidiary of another entity?
Yes
No
Parent Company Name
Relationship Description
% Owned
1b. Does the applicant have any subsidiaries?
Yes
No
Subsidiary Company Name
Relationship Description
% Owned
2. Is a formal safety program in operation?
Yes
No
Choose an answer
Safety Manual
Safety Position
Monthly Meetings
Osha
3. Any exposure to flammables, explosives, chemicals?
Yes
No
Explain
4. Any other insurance with this company?
Yes
No
List policy numbers
Line of Business
Policy Number
Add
Remove
5. Any policy or coverage declined, cancelled or non-renewed during the prior three (3) years for any premises or operations?
Yes
No
(Missouri applicants - do not answer this question)
Choose an answer
Non-Payment
Non-Renewal
Agent No Longer Presents Carrier
Underwriting
Condition Corrected
6. Any past losses or claims relating to sexual abuse or molestation allegations, discrimination or negligent hiring?
Yes
No
Explain
7. During the last five years (ten in ri), has any applicant been indicted for or convicted of any degree of the crime of fraud, bribery, arson or any other arson-related crime in connection with this or any other property?
Yes
No
In RI, this question must be answered by any applicant for property insurance. Failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one year of imprisonment
8. Any uncorrected fire and/or safety code violations?
Yes
No
List
Occur Date
Explanation
Resolution
Resolve Date
Add
Remove
9. Has applicant had a foreclosure, repossession, bankruptcy or filed for bankruptcy during the last five (5) years?
Yes
No
List
Occur Date
Explanation
Resolution
Resolve Date
Add
Remove
10. Has applicant had a judgement or lien during the last five (5) years?
Yes
No
List
Add
Remove
11. Has business been placed in a trust?
Yes
No
Name of trust:
12. Any foreign operations, foreign products distributed in usa, or us products sold / distributed in foreign countries?
Yes
No
Attach ACORD 815 for Liability Exposure and/or ACORD 816 for Property Exposure
Drop files here or
Select files
Max. file size: 32 MB.
13. Does applicant have other business ventures for which coverage is not requested?
Yes
No
Explain
14. Does applicant own / lease / operate any drones?
Yes
No
Describe use:
15. Does applicant hire others to operate drones?
Yes
No
Describe use:
Prior Carrier Information
Check if none
None
Carrier Information
Effective Date
Carrier
Policy #
Premium
Policy Type
Add
Remove
Loss History
Enter all claims or losses for the last 3 years
Check if none
None
Total losses:
Claims
Date of Claim
Line
Type / Description Claim
Ammount Paid
Open Claim (Yes / No)
Add
Remove
Attach Loss Summary for Additional Loss Information
Drop files here or
Select files
Max. file size: 32 MB.
Products You Are Interested In
(Required)
General Liability
Property
Commercial Auto
Truckers
Workers Compensation
Health
Life Insurance
General Liability
COVERAGES LIMITS
General Aggregate
Products and Comp/Ops Aggregate
Personal and Advertising Injury
Each occurrence
Damage to Renter Premises
Medical Expenses
Workers Compensation
EMPLOYERS LIABILITY
States
EACH ACCIDENT
DISEASE-POLICY LIMIT
DISEASE-EACH EMPLOYEE
INDIVIDUALS INCLUDED / EXCLUDED
PARTNERS, OFFICERS, RELATIVES (employed by business operations)
Individuals included / excluded
Name
Title / Relationship
Ownership %
INC / EXC
Add
Remove
RATING INFORMATION
Individuals included / excluded
Location
Categories, Duties, Classifications
Full Time Employees
Part Time Employees
Estimated Annual Payroll
Add
Remove
GENERAL INFORMATION
1. Does applicant own, operate or lease aircraft / watercraft?
Yes
No
Explain
2. Do / have past, present or discontinued operations involve(d) storing, treating, discharging, applying, disposing, or Transporting of hazardous material? (e.g. landfills, wastes, fuel tanks, etc)
Yes
No
Explain
3. Any work performed underground or above 15 feet?
Yes
No
Explain
4. Any work performed on barges vessels, docks, bridge over water?
Yes
No
Explain
5. Is applicants engaged in any other type of business?
Yes
No
Explain
6. Our subcontractors used?
Yes
No
Percent (%) of work contracted?
7. Any word subject without certificates of insurance?
Yes
No
Explain
8. Is it written safety program in operation?
Yes
No
Explain
9. Any group transportation provided?
Yes
No
Explain
10. Any employees 16 or over 60 years of age?
Yes
No
Explain
11. Any seasonal employees?
Yes
No
Explain
12. Is there any volunteer or donate to labor?
Yes
No
Explain
13. Any employees with physical handicaps?
Yes
No
Explain
14. Do you employees travel outside the state?
Yes
No
Explain
(Required)
15. Are athletic teams sponsored?
Yes
No
Explain
16. Are physicals required after offers of employment are made?
Yes
No
Explain
17. Any other insurance with this insurer?
Yes
No
Explain
18. Any prior coverage Declined / Canceled / Non-Renewed in the last three years?
Yes
No
Explain
19. Are employee health plans provided?
Yes
No
Explain
20. Do any employees perform work for other businesses or subsidiaries?
Yes
No
Explain
21. Do you lease employees to or from other employers?
Yes
No
Number of Employees
22. Do any employees predominantly work at home?
Yes
No
Number of Employees
23. Any tax liens or bankruptcy within the last five (5) years?
Yes
No
Please specify
24. Any undisputed and unpaid workers compensation premium due from you or any commonly managed or owned enterprises?
Yes
No
Explain including entity name(s) and policy number(s).
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