Loss Runs Request - New Step 1 of 7 14% Insured Name(Required) Phone(Required)Email(Required) Business Address(Required) Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Authorized Signer(Required) First Last Title(Required) Policy Type(Required) General Liability Umbrella/Excess Liability Commercial Auto Worker's Comp Other Please choose only ONE policy type. General LiabilityHow many General Liability carriers have you had in the last 5 years?(Required)12345General Liability Carrier #1Carrier Name(Required) Please list the insurance company that provided coverage, NOT the insurance agent/agency that assisted you with the policy.Policy Number(s)(Required) Dates of Coverage(Required) Please list the first effective date of the policy to the last expiration date on the policy. EXAMPLE: your coverage started April 1st, 2020 and ended on April 1st, 2023, please show dates of coverage as: 4/1/2020 - 4/1/2023.General Liability Carrier #2Carrier Name(Required) Please list the insurance company that provided coverage, NOT the insurance agent/agency that assisted you with the policy.Policy Number(s)(Required) Dates of Coverage(Required) Please list the first effective date of the policy to the last expiration date on the policy. EXAMPLE: your coverage started April 1st, 2020 and ended on April 1st, 2023, please show dates of coverage as: 4/1/2020 - 4/1/2023.General Liability Carrier #3Carrier Name(Required) Please list the insurance company that provided coverage, NOT the insurance agent/agency that assisted you with the policy.Policy Number(s)(Required) Dates of Coverage(Required) Please list the first effective date of the policy to the last expiration date on the policy. EXAMPLE: your coverage started April 1st, 2020 and ended on April 1st, 2023, please show dates of coverage as: 4/1/2020 - 4/1/2023.General Liability Carrier #4Carrier Name(Required) Please list the insurance company that provided coverage, NOT the insurance agent/agency that assisted you with the policy.Policy Number(s)(Required) Dates of Coverage(Required) Please list the first effective date of the policy to the last expiration date on the policy. EXAMPLE: your coverage started April 1st, 2020 and ended on April 1st, 2023, please show dates of coverage as: 4/1/2020 - 4/1/2023.General Liability Carrier #5Carrier Name(Required) Please list the insurance company that provided coverage, NOT the insurance agent/agency that assisted you with the policy.Policy Number(s)(Required) Dates of Coverage(Required) Please list the first effective date of the policy to the last expiration date on the policy. EXAMPLE: your coverage started April 1st, 2020 and ended on April 1st, 2023, please show dates of coverage as: 4/1/2020 - 4/1/2023. Umbrella/Excess LiabilityHow many Umbrella/Excess Liability carriers have you had in the last 5 years?(Required)12345Umbrella/Excess Liability Carrier #1Carrier Name(Required) Please list the insurance company that provided coverage, NOT the insurance agent/agency that assisted you with the policy.Policy Number(s)(Required) Dates of Coverage(Required) Please list the first effective date of the policy to the last expiration date on the policy. EXAMPLE: your coverage started April 1st, 2020 and ended on April 1st, 2023, please show dates of coverage as: 4/1/2020 - 4/1/2023.Umbrella/Excess Liability Carrier #2Carrier Name(Required) Please list the insurance company that provided coverage, NOT the insurance agent/agency that assisted you with the policy.Policy Number(s)(Required) Dates of Coverage(Required) Please list the first effective date of the policy to the last expiration date on the policy. EXAMPLE: your coverage started April 1st, 2020 and ended on April 1st, 2023, please show dates of coverage as: 4/1/2020 - 4/1/2023.Umbrella/Excess Liability Carrier #3Carrier Name(Required) Please list the insurance company that provided coverage, NOT the insurance agent/agency that assisted you with the policy.Policy Number(s)(Required) Dates of Coverage(Required) Please list the first effective date of the policy to the last expiration date on the policy. EXAMPLE: your coverage started April 1st, 2020 and ended on April 1st, 2023, please show dates of coverage as: 4/1/2020 - 4/1/2023.Umbrella/Excess Liability Carrier #4Carrier Name(Required) Please list the insurance company that provided coverage, NOT the insurance agent/agency that assisted you with the policy.Policy Number(s)(Required) Dates of Coverage(Required) Please list the first effective date of the policy to the last expiration date on the policy. EXAMPLE: your coverage started April 1st, 2020 and ended on April 1st, 2023, please show dates of coverage as: 4/1/2020 - 4/1/2023.Umbrella/Excess Liability Carrier #5Carrier Name(Required) Please list the insurance company that provided coverage, NOT the insurance agent/agency that assisted you with the policy.Policy Number(s)(Required) Dates of Coverage(Required) Please list the first effective date of the policy to the last expiration date on the policy. EXAMPLE: your coverage started April 1st, 2020 and ended on April 1st, 2023, please show dates of coverage as: 4/1/2020 - 4/1/2023. Commercial AutoHow many Commercial Auto carriers have you had in the last 5 years?(Required)12345Commercial Auto Carrier #1Carrier Name(Required) Please list the insurance company that provided coverage, NOT the insurance agent/agency that assisted you with the policy.Policy Number(s)(Required) Dates of Coverage(Required) Please list the first effective date of the policy to the last expiration date on the policy. EXAMPLE: your coverage started April 1st, 2020 and ended on April 1st, 2023, please show dates of coverage as: 4/1/2020 - 4/1/2023.Commercial Auto Carrier #2Carrier Name(Required) Please list the insurance company that provided coverage, NOT the insurance agent/agency that assisted you with the policy.Policy Number(s)(Required) Dates of Coverage(Required) Please list the first effective date of the policy to the last expiration date on the policy. EXAMPLE: your coverage started April 1st, 2020 and ended on April 1st, 2023, please show dates of coverage as: 4/1/2020 - 4/1/2023.Commercial Auto Carrier #3Carrier Name(Required) Please list the insurance company that provided coverage, NOT the insurance agent/agency that assisted you with the policy.Policy Number(s)(Required) Dates of Coverage(Required) Please list the first effective date of the policy to the last expiration date on the policy. EXAMPLE: your coverage started April 1st, 2020 and ended on April 1st, 2023, please show dates of coverage as: 4/1/2020 - 4/1/2023.Commercial Auto Carrier #4Carrier Name(Required) Please list the insurance company that provided coverage, NOT the insurance agent/agency that assisted you with the policy.Policy Number(s)(Required) Dates of Coverage(Required) Please list the first effective date of the policy to the last expiration date on the policy. EXAMPLE: your coverage started April 1st, 2020 and ended on April 1st, 2023, please show dates of coverage as: 4/1/2020 - 4/1/2023.Commercial Auto Carrier #5Carrier Name(Required) Please list the insurance company that provided coverage, NOT the insurance agent/agency that assisted you with the policy.Policy Number(s)(Required) Dates of Coverage(Required) Please list the first effective date of the policy to the last expiration date on the policy. EXAMPLE: your coverage started April 1st, 2020 and ended on April 1st, 2023, please show dates of coverage as: 4/1/2020 - 4/1/2023. Worker's CompHow many Worker's Comp carriers have you had in the last 5 years?(Required)12345Worker's Comp Carrier #1Carrier Name(Required) Please list the insurance company that provided coverage, NOT the insurance agent/agency that assisted you with the policy.Policy Number(s)(Required) Dates of Coverage(Required) Please list the first effective date of the policy to the last expiration date on the policy. EXAMPLE: your coverage started April 1st, 2020 and ended on April 1st, 2023, please show dates of coverage as: 4/1/2020 - 4/1/2023.Worker's Comp Carrier #2Carrier Name(Required) Please list the insurance company that provided coverage, NOT the insurance agent/agency that assisted you with the policy.Policy Number(s)(Required) Dates of Coverage(Required) Please list the first effective date of the policy to the last expiration date on the policy. EXAMPLE: your coverage started April 1st, 2020 and ended on April 1st, 2023, please show dates of coverage as: 4/1/2020 - 4/1/2023.Worker's Comp Carrier #3Carrier Name(Required) Please list the insurance company that provided coverage, NOT the insurance agent/agency that assisted you with the policy.Policy Number(s)(Required) Dates of Coverage(Required) Please list the first effective date of the policy to the last expiration date on the policy. EXAMPLE: your coverage started April 1st, 2020 and ended on April 1st, 2023, please show dates of coverage as: 4/1/2020 - 4/1/2023.Worker's Comp Carrier #4Carrier Name(Required) Please list the insurance company that provided coverage, NOT the insurance agent/agency that assisted you with the policy.Policy Number(s)(Required) Dates of Coverage(Required) Please list the first effective date of the policy to the last expiration date on the policy. EXAMPLE: your coverage started April 1st, 2020 and ended on April 1st, 2023, please show dates of coverage as: 4/1/2020 - 4/1/2023.Worker's Comp Carrier #5Carrier Name(Required) Please list the insurance company that provided coverage, NOT the insurance agent/agency that assisted you with the policy.Policy Number(s)(Required) Dates of Coverage(Required) Please list the first effective date of the policy to the last expiration date on the policy. EXAMPLE: your coverage started April 1st, 2020 and ended on April 1st, 2023, please show dates of coverage as: 4/1/2020 - 4/1/2023. Other Commercial Insurance PolicyHow many Other carriers have you had in the last 5 years?(Required)12345Other Carrier #1Carrier Name(Required) Please list the insurance company that provided coverage, NOT the insurance agent/agency that assisted you with the policy.Policy Number(s)(Required) Dates of Coverage(Required) Please list the first effective date of the policy to the last expiration date on the policy. EXAMPLE: your coverage started April 1st, 2020 and ended on April 1st, 2023, please show dates of coverage as: 4/1/2020 - 4/1/2023.Other Carrier #2Carrier Name(Required) Please list the insurance company that provided coverage, NOT the insurance agent/agency that assisted you with the policy.Policy Number(s)(Required) Dates of Coverage(Required) Please list the first effective date of the policy to the last expiration date on the policy. EXAMPLE: your coverage started April 1st, 2020 and ended on April 1st, 2023, please show dates of coverage as: 4/1/2020 - 4/1/2023.Other Carrier #3Carrier Name(Required) Please list the insurance company that provided coverage, NOT the insurance agent/agency that assisted you with the policy.Policy Number(s)(Required) Dates of Coverage(Required) Please list the first effective date of the policy to the last expiration date on the policy. EXAMPLE: your coverage started April 1st, 2020 and ended on April 1st, 2023, please show dates of coverage as: 4/1/2020 - 4/1/2023.Other Carrier #4Carrier Name(Required) Please list the insurance company that provided coverage, NOT the insurance agent/agency that assisted you with the policy.Policy Number(s)(Required) Dates of Coverage(Required) Please list the first effective date of the policy to the last expiration date on the policy. EXAMPLE: your coverage started April 1st, 2020 and ended on April 1st, 2023, please show dates of coverage as: 4/1/2020 - 4/1/2023.Other Carrier #5Carrier Name(Required) Please list the insurance company that provided coverage, NOT the insurance agent/agency that assisted you with the policy.Policy Number(s)(Required) Dates of Coverage(Required) Please list the first effective date of the policy to the last expiration date on the policy. EXAMPLE: your coverage started April 1st, 2020 and ended on April 1st, 2023, please show dates of coverage as: 4/1/2020 - 4/1/2023. Consent I agree and consent to the following:I authorize My Insurance Group to request a copy of my entire Loss History / a current Loss Run for policy(ies) listed above and for any other policies pertaining to my account. I understand that I must electronically sign the loss run request that will follow.CAPTCHA
