Application – Atlantic Mutual Insurance

ATLANTIC MUTUAL LEGAL DEFENSE INSURANCE COMPANY, INC.

COMMERCIAL INSURANCE APPLICATION
APPLICANT INFORMATION
Are you an insurance agent filling out this form for the insured? *

YES NO
Agency Name:
Individual Completing This Application:

First Name Last Name
Phone Number
E-mail
[email protected]
Producer Name:
Producer License #:
ACCOUNT INFORMATION
Requested Effective Date:

Month Day Year
Date
FEIN #: *
Name of Insured: *
Contact Name: *
Title: *
Phone Number *
E-mail *
This will be the e-mail of the insured responsible for signing this form if being filled by an agent.
Business Mailing Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Has insured been involved in any lawsuit or legal claim in the past 5 years? *

YES NO
Have complaints been filed against insured with a state, county or government agency? *

YES NO
Additional Insureds to be listed on the policy
Insured 1:
Insured 2:
Insured 3:
Insured 4:
Required Underlying Insurance Information
General Liability Carrier:
Effective Date:

Month Day Year
Limits:
Directors & Officers Carrier:
Effective Date:

Month Day Year
Limits:
Property Carrier
Effective Date:

Month Day Year
Insured Value:
Wind Carrier ( if different than property carrier )
Effective Date:

Month Day Year
Insured Value:
Election of Optional Coverage
For an additional premium, you may elect to purchase an extended reporting period (5 years) for directors or officers who no longer serve on the board. Do you want to purchase the coverage? *

YES NO
PREMISES INFORMATION
Total Unit Count For all Risk Types Except HOA: *
* Condominium Association & Co-Op (# of Units) / Homeowners Association (# of Homes) * Apartment Complex (# of Apartments) / Hotel (# of Rooms) / Commercial Office Structure (# of Tenents)
Total HOA Homes: *
Please complete the following for each physical location or upload Acord Form 139 below
You may upload ACORD form 139 here. Please put risk type under "class code" and unit count under "rate cost".

Please put risk type under "class code" and unit count under "rate cost".
Cancel of
Locations
SIGNATURE PAGE
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A FELONY ( IN FLORIDA, A PERSON IS GUILTY OF A FELONY OF THE THIRD DEGREE).

The undersigned states that he/she is an authorized representative of the Applicant and declares to the best of his/her knowledge and belief and after reasonable inquiry, that the statements set forth in this Application (and any attachments submitted with this Application) are true and complete and may be relied upon by Company in quoting and issuing the policy. If any of the information is this Application changes prior to the effective date of the policy, the Applicant will notify the Company of such changes and the Company may modify or withdraw the quote or binder.
Check here if you understand and agree:

I AGREE
Name *

First Name Last Name
Date *

Month Day Year
Date
Signing the form below will automatically submit the application.
By clicking submit below, the application will be emailed to the insured to request their signature.
Should be Empty:

ATLANTIC MUTUAL LEGAL DEFENSE INSURANCE COMPANY, INC.

APPLICANT INFORMATION

ACCOUNT INFORMATION

Additional Insureds to be listed on the policy

Required Underlying Insurance Information

Election of Optional Coverage

PREMISES INFORMATION

Please complete the following for each physical location or upload Acord Form 139 below

SIGNATURE PAGE

By clicking submit below, the application will be emailed to the insured to request their signature.