Get a Quote Drop us a line and one of our representatives will get back to you. Auto Health Motorcycle Boat Homeowners General Liability Commercial Property Professional Liability Worker's Compensation Cyber Liability Life Insurance Builders Risk Auto Insurance Questionnaire (#19) AUTO INSURANCEGet the best car insurance in MiamiGet a Quote today! Enrollment consent form I, , give my permission to to serve as the health insurance Agent or broker for myself and my entire household if applicable, for purposes of enrollment in a Qualified Health Plan offered on the Federally Facilitated Marketplace. By consenting to this agreement, I authorize the above-mentioned Agent to view and use the confidential information provided by me in writing, electronically, or by phone only for one or more of the following: Searching for an existing Marketplace application Completing an application for eligibility and enrollment in a Marketplace Qualified Health Plan or other government insurance affordability programs, such as Medicaid and CHIP or advance tax credits to help pay for Marketplace premiums Providing ongoing account maintenance and enrollment assistance, as necessary Responding to inquiries from the Marketplace regarding my application I understand that the Agent will not use or share my personally identifiable information (PII) for any purposes other than those listed above. The Agent will ensure that my Pll is kept private and safe when collecting, storing, and using my Pll for the stated purposes above. I confirm that the information I provide for entry on my Marketplace eligibility and enrollment application will be true to the best of my knowledge. I confirm that I have reviewed my completed application and that all information is accurate. I understand that I do not have to share additional personal information about myself or my health with my Agent beyond what is required on the application for eligibility and enrollment purposes. I understand that my consent remains in effect until I revoke it, and I may revoke or modify my consent at any time by contacting my Agent or by revoking it through my HealthSherpa dashboard.Primary Writing AgentName of primary writing AgentAgent National Producer NumberPhone NumberEmail AddressAgencyName of AgencyAgency National Producer NumberOwner of AgencyAgency Phone NumberAgency Email AddressPrimary ApplicantName of primary household contactPhone NumberEmail AddressPrimary Contact Signature Sign Here DateSubmit Motorcycle Questionnaire MOTORCYCLE INSURANCE QUESTIONAIREMotorcycle Insurance PDFPDF File UploadPDF File Upload Today's Date Referred By- Select -Ramfis MarmolejosJuan Jose TamayoJavier MackaySteven MurphyOtherDesired Effective Date RIDER INFORMATIONInsured Name'sAddressEmailPhone/MobileMarital StatusGender Male FemaleDriver's License #Date of BirthDoes rider have motorcycle endorsement added on driver’s license? Yes NoHas the rider owned or been insured on a motorcycle within the past 5 years? Yes NoIf yes, how many year’s?MC Safety Foundation Course? Yes NoMember of MC Association? Yes NoAre you a Homeowner? Yes NoAny Tickets or Accidents in past 5 years (MC or Auto) ? VEHICLE INFORMATIONYear:Make:Model:VIN:CCs:Cost New / Actual Value:Date Purchased:Is motorcycle garaged: Yes NoGaraging Address (if different than above):Current Motorcycle Insurance? Yes NoIf yes, provide: Current Carrier:# of Months w/Carrier:Exp. Date:Premium:Coverage RequestedBI/PD/GST: MED:UM/UIM:COMP/COLL:RD ASST:UMPD:Signature Sign Here SUBMIT Boat Insurance Questionnaire BOAT INSURANCE QUESTIONAIREBoat Insurance PDFFile UploadPDF File Upload Name of Owner(s)EmailMailing Address (If Different)Driver’s License Referred By- Select -Ramfis MarmolejosJuan Jose TamayoJavier MackaySteven MurphyOtherTelephone NumberGaraging AddressMarital StatusDate of BirthAdditional informationCurrent /Prior Insurance CoveragesAny claims in the past 5 years?How long with Current Insurance Expiration Date Homeowner?- Select -YesNoBoat makeYearHow many feet?Boat ModelVessel #/ VIN number Inboard/outboardSignature Sign Here Note: Please upload all corresponding documents: Boat Registration, Drivers license, Boaters Course completion, Boaters License, etc. to our website our email info@mad-insurance.comSUBMIT Homeowners Insurance Questionnaire HOMEOWNERS INSURANCE QUESTIONAIREHomeowners Insurance PDFFile UploadPDF File Upload NameEmailMailing addressReferred By- Select -Ramfis MarmolejosJuan Jose TamayoJavier MackaySteven MurphyOtherPhone numberProperty AddressRental property or Owner-occupied - Select -Rental property-tenant-occupiedOwner-occupiedNew purchase/currently insured/uninsured- Select -New purchaseCurrently insuredUninsuredI'm confusedRoof type—Tile/shingle/cement/metal/other- Select -TileShingleCementMetalMetalAC, Plumbing, and electrical updates? If so, what years?Claims in last 5 years? If so, explain. (open or closed) Type of claim.Shutters/no shutters- Select -I have shuttersI do not have shuttersOriginal year of Roof? Year repaired/replaced? Updates?Flood policy required? If so, is there an active policy?Valid wind mitigation or 4-point inspection available?- Select -I have both wind & 4-pt inspectionsI only have a wind mitigationI only have a wind mitigationI only have a wind mitigationI only have a wind mitigationSignature Sign Here Note: Please attach all corresponding documents: Wind mitigation inspection /4 point inspection/elevation certificate/ Drivers licenses/ Current insurance declarations page/ lender requirement for closing. SUBMIT General Liability Questionnaire GENERAL LIABILITY QUESTIONAIREGeneral Liability Insurance PDFFile UploadPDF File Upload General Information:Applicant name Telephone numberEmailReferred By- Select -Ramfis MarmolejosJuan Jose TamayoJavier MackaySteven MurphyOtherCompany Information:Legal Business name FEINPartnership/Corp/LLC Business address Website Phone numberYears in Business Detailed description of business: Projected annual revenues: Prior Coverage (f applicable):Prior CompanyLength of CoverageTotal PremiumRenewal DateAny claims in the past?- Select -YesNoAdditional Information: Please explain your desired coverages . Signature Sign Here SUBMIT Commercial Property Questionnaire Commercial Property Questionaire Commercial Property Insurance PDFFile UploadPDF File Upload Contact Information:First NameLast NameCompany NameReferred By- Select -Ramfis MarmolejosJuan Jose TamayoJavier MackaySteven MurphyOtherAddressCityStateZipEmailPhone Requested Effective Date:TELL US ABOUT Y OUR OPERA TIONSDescription of Operations Year StartedYear ExperienceTELL US ABOUT YOUR BUILDINGYear BuildIf over 15 years, has property been updated? Yes NoYear Updated RoofPlumbingElectricHVACDescription of UpdatesArea# of StoriesFull BathHalf BathRoof- Select -COMPOSITIONWOOD SHRINGLESLATEMETALTAR/GRAVELFLATOTHERConstruction- Select -FRAMEBRICK VENEERMETAL/ICMFIRE RESISTIVEMASONRYHeating Central Floor Furnace Electric Heater Fireplace Gas Space Heater Vented or Un-VentedCooling Central Window Units Two Pipe System Any construction, renovation or improvements planned in the next 12 months? Yes NoIf yes, describe Residential Use? Yes NoIf yes, describe Security: check all that apply Monitored Burglar Alarm Monitored Fire Alarm Deadbolt on all Doors Smoke Alarms Carbon-Monoxide Alarms Bars on WindowsLOST HISTORYProvide summary of losses in the last three (3) years (Date of Loss, Description of Loss, Amount Paid) Insurance Declined, Cancelled or Non-Renewed in last three (3) years? Yes NoCOVERAGE OPTIONBuilding Limit:Checkbox Field Replacement Cost Actual Cash ValueContents Limit:Detached StructuresLiability- Select -$100,000$300,000$500,000$1,000,000$2,000,000Other Loss of Rents Ordinance & Law Additional BuildingsAdditional InformationSignature Sign Here SUBMIT Professional Liability Miscellaneous Professional Liability QuestionnaireProfessional Liability Insurance PDFFile UploadPDF File Upload Section 1: General Information (Note: If any affiliated entities or subsidiaries are to be included, please attach an organizational chart, and complete all questions in this application with respect to all entities to be covered)Applicant:Physical Address:City, State, ZIP:Mailing Address:City, State, ZIP:Website:Contact Name:Contact Phone:Contact E-mail:Year Established:Nature of Operations:Referred By- Select -Ramfis MarmolejosJuan Jose TamayoJavier MackaySteven MurphyOther Additional documentation requested: Résumés of principals, partners and key employees Sample client contract Sample sub-contractor contract, if applicable Marketing materials Section 2: Operations1) Please provide annual revenues for:Domestic:Foreign:Total:Latest fiscal year endTotal number of employees-USTotal number of employees-OTHERTotal number of employees-TOTALCurrent fiscal year (projected)Annual sales or revenue-USAnnual sales or revenue-OTHERAnnual sales or revenue-TOTALNext year (projected)Estimated total number of records-USEstimated total number of records-OTHEREstimated total number of records-TOTALSECTION II – CURRENT COVERAGECURRENT CARRIEREXPIRATION DATEANNUAL PREMIUMLIMITSRETENTION / DEDUCTIBLERETROACTIVE DATECURRENT CARRIER-1EXPIRATION DATE-1ANNUAL PREMIUM-1LIMITS-1RETENTION / DEDUCTIBLE-1RETROACTIVE DATE-1CURRENT CARRIER-2EXPIRATION DATE-2ANNUAL PREMIUM-2LIMITS-2RETENTION / DEDUCTIBLE-2RETROACTIVE DATE-2SECTION III - LOSS EXPERIENCE(Explain any “Yes” responses, including corrective actions and damages incurred on the ADDITIONAL INFORMATION page below): 1. During the past three (3) years whether insured or not, have you sustained any losses due to unauthorized access, unauthorized use, virus, denial of service attack, electronic media liability, data breach, data theft, fraud, electronic vandalism, sabotage or other similar electronic security events? Yes No2. Within the past three (3) years, have you experienced any network related business interruption exceeding eight (8) hours other than planned maintenance? Yes No3. During the last three (3) years, has anyone alleged that you were responsible for damage to their computer system(s) arising out of the operation of Applicant’s computer system(s)? Yes No4. During the last three (3) years, have you received a complaint or other proceeding (including an injunction or other request for non-monetary relief) arising out of intellectual property infringement, copyright infringement, media content, or advertising material? Yes No5. During the last three (3) years, has anyone made a demand, claim, complaint, or filed a lawsuit against you alleging invasion of, or interference with rights of privacy, or the inappropriate disclosure of personally identifiable information (PII)? Yes No6. During the last three (3) years, have you been the subject of an investigation or action by any regulatory or administrative agency for privacy-related violations? Yes NoSignature Sign Here SUBMIT Worker's Compensation Download your Workers' Compensation Insurance Questionnaire and upload below: Leave this field blank Name Email Phone Referred By Notes Upload Choose file Uploading… (0%) Browse A file with this name has already been uploaded. This file type isn’t allowed. This file size is too big. Submit Cyber Security Liability 9050 PINES BLVD. STE 415-411 Pembroke Pines, FL 33024 office: (954) 542-9232 fax: (954) 541-9236 PROFESSIONAL LIABILITY APPLICATIONCOVERAGES E., F., AND G. ARE CLAIMS MADE AND REPORTED COVERAGES. CLAIM EXPENSES UNDER COVERAGES E., F., AND G. ARE INCLUDED WITHIN THE AVAILABLE LIMIT OF INSURANCE. ANY CLAIM EXPENSES PAID UNDER THIS COVERAGE FORM WILL REDUCE THE AVAILABLE LIMITS OF INSURANCE AND MAY EXHAUST THEM COMPLETELY. PLEASE READ THE ENTIRE POLICY CAREFULLY. Certain terms have specific meaning as defined in the policy form and noted in bold. Throughout this Application the words "you" and "your" refer to the Named Insured shown in the Declarations, and any other person or organization qualifying as a Named Insured under the proposed policySECTION I – GENERAL INFORMATIONInsured Full Name Phone/MobileEmailWebsiteAddressCityStateZip CodePredominant business activity and SIC code: Please list all subsidiaries for which coverage is requested under this policy. To enter more information, please use the Additional information page attached to this application.US / CanadaOther CountriesTotalTotal number of employeesTotal number of employees-USTotal number of employees-OTHERTotal number of employees-TOTALAnnual sales or revenueAnnual sales or revenue-USAnnual sales or revenue-OTHERAnnual sales or revenue-TOTALEstimated total number of recordsEstimated total number of records-USEstimated total number of records-OTHEREstimated total number of records-TOTALSECTION II – CURRENT COVERAGECURRENT CARRIEREXPIRATION DATEANNUAL PREMIUMLIMITSRETENTION / DEDUCTIBLERETROACTIVE DATECURRENT CARRIER-1EXPIRATION DATE-1ANNUAL PREMIUM-1LIMITS-1RETENTION / DEDUCTIBLE-1RETROACTIVE DATE-1CURRENT CARRIER-2EXPIRATION DATE-2ANNUAL PREMIUM-2LIMITS-2RETENTION / DEDUCTIBLE-2RETROACTIVE DATE-2SECTION III - LOSS EXPERIENCE(Explain any “Yes” responses, including corrective actions and damages incurred on the ADDITIONAL INFORMATION page below): 1. During the past three (3) years whether insured or not, have you sustained any losses due to unauthorized access, unauthorized use, virus, denial of service attack, electronic media liability, data breach, data theft, fraud, electronic vandalism, sabotage or other similar electronic security events? Yes No2. Within the past three (3) years, have you experienced any network related business interruption exceeding eight (8) hours other than planned maintenance? Yes No3. During the last three (3) years, has anyone alleged that you were responsible for damage to their computer system(s) arising out of the operation of Applicant’s computer system(s)? Yes No4. During the last three (3) years, have you received a complaint or other proceeding (including an injunction or other request for non-monetary relief) arising out of intellectual property infringement, copyright infringement, media content, or advertising material? Yes No5. During the last three (3) years, has anyone made a demand, claim, complaint, or filed a lawsuit against you alleging invasion of, or interference with rights of privacy, or the inappropriate disclosure of personally identifiable information (PII)? Yes No6. During the last three (3) years, have you been the subject of an investigation or action by any regulatory or administrative agency for privacy-related violations? Yes NoSignature Sign Here SUBMIT Life Insurance Questionnaire LIFE INSURANCE QUESTIONAIRE Preliminary Inquiry—Not an application for life insurance. To help you obtain competitive life insurance quotes, please provide information on your medical history, doctors and other factors that may impact underwriting. This preliminary inquiry is not an actual application for insurance and does not guarantee any coverage will be offered. This information is held confidential and released only to parties named below.Life Insurance PDFFile UploadPDF File Upload PERSONAL INFORMATIONProducer Name:Date :First NameMiddle NameLast NameSex Male FemaleSSNDate of BirthCitizenshipDriver's License Info: State:#Present AddressReferred By- Select -Ramfis MarmolejosJuan Jose TamayoJavier MackaySteven MurphyOtherCityStateZip What is the total amount of life insurance on your life (including any provided by your employer)? Company Name Death Benefit Year Issued Beneficiary Will the insurance being applied for replace, change or affect any of the insurance noted above? Yes NoIf yes, which policies?Do you have any other pending (or anticipated) applications for life insurance? Yes NoIf yes, please provide insurance company name, face amount, date of application:TOBACCO USEHave you had a life insurance application declined, rated, postponed, withdrawn, modified, canceled, or not renewed? Yes NoIf yes, list date and reason:EXISTING INSURANCE COVERAGEIf yes, are you a current user? Yes No useIf no, date of last use: Signature Sign Here SUBMIT Builders Risk Builders Risk Application Builders Risk Application PDFFile UploadPDF File Upload Insured Name:Mailing Address:Insured Name:Mailing Address:Insured Is: Owner ContractorYears in Business:Contractor Name & Mailing Address (If different from named insured):Loss History (if any)YearTotal IncurredDescriptionTotal number of employees-OTHERTotal number of employees-OTHERTotal number of employees-OTHERTotal number of employees-OTHERTotal number of employees-OTHERTotal number of employees-OTHERTotal number of employees-OTHERTotal number of employees-OTHERTotal number of employees-OTHERGeneral InformationLocation Address:Project Type:Dropdown- Select -Residential - SIngle FamilyResidential - Two-FamilyCommercialRenovation Information (if new construction, please skip this section) Value of existing structure:Value of work to be completed:Estimated time needed for completion:Year BuiltIs work structural in nature? Yes NoIf work is not structural, please describe nature of renovations (e.g., recarpeting, fixtures, etc.):Construction InformationEstimated Start Date:Estimated Completion Date:Is project currently under construction? Yes NoYear BuiltEstimated term of construction:Months:% Completed:Construction type:- Select -FrameJMNoncombustibleMNCFire resistiveSquare footage:# of Stories: # of Buildings:Protection ClassApproximate distance between buildings:Intended occupancy:Optional Coverages (check any that apply) Windstorm (coastal risks):Distance to coast:Is project location eligible for coverage in a wind pool? Yes NoIf yes, if maximum limit available in wind pool? Yes NoLimits of Liability Total completed project value:Temporary Storage:Transit:Soft Costs:Loss of Rents:Loss of Earnings: SecurityIs the project site fenced? Yes NoIs the project site lighted? Yes NoIs a security guard on site during non-working hours? Yes NoIf yes, please provide hours on site:Loss ControlIs debris removed from the site at regular intervals? Yes NoFrequency:Is a public water supply in service at the site? Yes NoIs there a brush area? Yes NoIf yes, please provide the clearance from the site Additional Insured, Mortgagee, Loss Payee Information (if applicable) TypeNameAddressTotal number of employees-OTHERTotal number of employees-OTHERTotal number of employees-OTHERTotal number of employees-OTHERTotal number of employees-OTHERTotal number of employees-OTHERTotal number of employees-OTHERTotal number of employees-OTHERTotal number of employees-OTHERApplicant Signature Sign Here Producer Signature Sign Here DateDateSUBMIT Get in Touch 9050 Pines Blvd, Suite 415-418Pembroke Pines FL 33024 Phone: 954.541.9232 / 305. 594.8696 Email: info@mad-insurance.com Hours of Operation MONDAY - FRIDAY 9:30AM - 6PM SATURDAY & SUNDAY By appointment only We are available 24/7 via text (954) 541-9232 Get A Quote FollowFollowFollowFollow
