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| General Information |
| Name of Business |
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| Contact Name |
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| Street Address |
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| City |
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| State |
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| ZIP Code |
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| County |
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| Email |
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| Business Telephone |
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| Fax |
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| Current Insurance Company (not agency) |
| Company Name |
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| Policy Expiration Date |
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| Current Coverages |
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| About Your Business |
| Number of full-time employees |
|
| Number of part-time employees |
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| How long in business |
years |
| How many locations |
|
| Annual Sales (in dollars) |
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| Please give a brief description of your business and clientele |
|
|
| Property / Premises Information 1 |
| Street Address |
|
Owner
Tenant
Year Built
% Occupied
Sprinklers?
Yes
No |
| Construction Type
# Stories
#Basements
Square Footage
|
Burglar Alarm
Yes
No Building Value $
Contents $
|
| Other Property ( Specify) |
|
|
| Property / Premises Information 2 |
| Street Address |
|
Owner
Tenant
Year Built
% Occupied
Sprinklers?
Yes
No |
| Construction Type
# Stories
#Basements
Square Footage
|
Burglar Alarm
Yes
No Building Value $
Contents $
|
| Other Property ( Specify) |
|
|
|
| Property / Premises Information 3 |
| Street Address |
|
Owner
Tenant
Year Built
% Occupied
Sprinklers?
Yes
No |
| Construction Type
# Stories
#Basements
Square Footage
|
Burglar Alarm
Yes
No Building Value $
Contents $
|
| Other Property (specify) |
|
|
| Liability |
| Class of Business |
|
| Other |
|
| Annual Gross Sales(before taxes) |
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| Number of employees |
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| Annualized Payroll |
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| Cost of any Subcontracted Work |
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| Limits Requested |
$300,000
$500,000
$1,000,000
$2,000,000 |
| Describe any claims you've had in the past 5 years |
|
| Additional Comments |
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