Business Information

    Year Business Started: _____________________________________________________

    # of years experience:  _____________________________________________________

    # of full time employees:_______

    # of part time employees: _______

    Federal ID #: _____________

    Type of Business:     C" Corporation / "S" Corporation / Partnership / Individual / LLC / LLP

Property:
 

	Location #1	Location#2
Building Value:
Square Footage:
% Occupied By Insured:
# of Stories:
Construction of building:
Year Built:
Year updated - roof:
Year updated - electric:
Year updated - HVAC:
Year updated - Plumbing
Fire extinguishers:	Yes or  No	Yes or  No
Smoke detectors:	Battery or Wired	Battery or Wired
Alarm:	Local  or Central	Local  or Central
Protection Class:
% of building sprinklered:
Contents value:
Business income value:
Period of restoration:	1/3   1/4    1/6    1/12 or Actual	1/3   1/4    1/6    1/12 or Actual
Building possession:	Owned     or   Leased	Owned     or   Leased
PTY deduct (Requested)	$500      $1,000    $5,000	$500      $1,000    $5,000
Mortgagee*	Yes or  No	Yes or  No
Additional Insured*:	Yes or  No	Yes or  No

*Please complete information below





Location # 2 Address _________________________________________________________________________________

Mortgagee/Additional Insured:

Name:
Address:
Interest

General Liability:

	Location #1	Location #
Occurrence limit:
Aggregate limit:
Fire legal liability limit:
Gross annual sales:
Payroll:
Payroll classification:
Additional insureds*	Yes or  No	Yes or  No
Sub-contractors used:	Yes or  No	Yes or  No
Cost of sub-contractors:
Sub. Agreements used**:	Yes or  No	Yes or  No
Sub. certs. obtained:	Yes or  No	Yes or  No
Any vacant land - acres
Any Leased buildings. -#:

* Please complete information below
** Please obtain comp of sub-contractor agreement

Additional Insureds:

Name
Address:
Interest:

Name:
Address:
Interest:

Crime:

	Location #1	Location #2
Accounts receivable:
Employee dishonesty:
Monies & securities - In
Monies & securities - Out
Valuable papers/records:
Forgery & Alterations:

Automobile:

	Policy level coverage
Limit of liability:
Hired/Non-owned Liability:	Yes or  No
Hired physical damage:
Cost of hire:
Driver other car	Yes or  No
# Of people - D.O.C
Names of  D.O.C drivers:

	Vehicle #1	Vehicle #2	Vehicle #3	Vehicle #4
Year:
Make:
Model:
Vin #:
Cost New:
GVW:
Use*:	C   S   R   P	C   S   R   P	C   S   R   P	C   S   R   P
Collision	Yes or  No	Yes or  No	Yes or  No	Yes or  No
Deductible:
Comprehensive:	Yes or  No	Yes or  No	Yes or  No	Yes or  No
Deductible:
Radius of Use:	50   100   200	50   100   200	50   100   200	50   100   200
Garaging Zip Code:
Loss Payee:	Yes or  No	Yes or  No	Yes or  No	Yes or  No

* Vehicle Use: C = Commercial   S =  Service    R =   Retail Delivery      P =  Personal

 Loss Payees:

Name:
Address:
Vehicles:

Name:
Address:
Vehicle:

Driver Schedule:

	Driver #1	Driver #2	Driver #3	Driver #4
Name:
State Licensed:
Date of Birth:
Licensed #:

Inland Marine:

	#1	#2	#3	#4
Year:
Make:
Model:
Serial #:
Actual Cash Value
Deductible

Installation floater:          Amount of coverage desired:   $______________________
Blanket Value:                                            $___________________
Unscheduled Equipment Value:                     $___________________    
Maximum Value Per Item - Unscheduled:       $___________________

Computer Equipment:

	Hardware	Software
Description:
Value:

Boiler & Machinery:

	Location #1	Location #2
Building Limit:
Contents Limit:
Machinery/Equipment Limit:
Deductible:

Workers' Compensation:

	Class Code	Class Code	Class Code	Class Code
Class Code:
Class Description:
Payroll:
# of full time EMP:
# of part time EMP:

Corporate Officers:

	President	V. President	Secretary	Treasurer
Name:
Date of birth:
Social security #:
% of ownership:
included/excluded:
Annual salary:
Officers duties:

Umbrella:

Limit of Liability Requested:   $__________________________________________________________________

Self-insured retention:            $0   $5,000   $10,000   $20,000

Notes:
             ____________________________________________________________
             ____________________________________________________________
             ____________________________________________________________
             ____________________________________________________________


Additional Information Needed to Provide Quote:

            3 years hard copy loss runs          INCL /  MISSING / OHTER (Explain)

            Copy of employment application   INCL /  MISSING / OHTER (Explain)

            Copy of employee handbook        INCL /  MISSING / OHTER (Explain)

            Copy of most recent financials      INCL /  MISSING / OHTER (Explain)

            Copy of marketing materials         INCL /  MISSING / OHTER (Explain)
               (Brochures, Pamphlets, etc.)

Additional Coverage Requested - Supplemental Required:

	Yes	No
Liquor Liability:
Professional Liability:
Directors & Officers Liability:
Pollution:
Garage Liability/Garagekeepers:
Marine Liability:
Aircraft Liability:
Flood coverage:
Earthquake Coverage:
Employment Practices Liability - Stand Alone

Current/Prior Insurance Information:

	2011	2010	2009	2008
Carrier:
Expiration Date:
Property Premium:
Liability Premium:
Auto Premium:
WC Premium: