| NAPO member ID#: |
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Required |
| Contact Name: |
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Required |
| Company Name: |
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Required |
| Location Address: |
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| (Street) |
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Required |
| (City) |
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Required |
| (County) |
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Required |
| (State) |
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Required |
| (Zip) |
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Required |
| Mailing Address: |
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| (Street) |
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Required |
| (City) |
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Required |
| (County) |
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Required |
| (State) |
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Required |
| (Zip) |
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Required |
| Phone: |
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Required |
| Fax: |
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| Email: |
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Required |
If we have any questions,
who should we contact? |
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Required |
What is the legal structure
of your business? |
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| Years in business? |
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2. We realize that many NAPO members operate their business from their home, while others lease office space or even own their own buildings. The following information will help us properly understand your particular circumstances: |
Do you operate from your home, apartment, or condo?
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Do you lease office space?
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If yes, are you responsible for the building glass/windows?
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Do you own your own building?
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Do you have a sprinkler system?
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What is the construction of the building that houses your office?
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What is the total square footage of your office?
sq ft.
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Required |
If you own your own building and want us to provide property insurance on your building, what is the reconstruction cost of the building?
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What is the total replacement value of your business property (desks, chairs, supplies, inventory, etc.)?
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Required |
What is the replacement cost of your computers?
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Do you have any employees, other than yourself?
If so, how many?
Do you provide benefits?
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What is the annual payroll for employees (excluding the business owner)?
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Required |
What are your estimated annual revenues?
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Required |
Please provide your FEIN (Federal Employee Identification Number)
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| 3. Please list below any business automobiles for which you would like us to provide insurance. |
| Vehicle List |
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| 4. Insurance Claims: |
Who is your current insurance carrier?
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What is your policy effective date?
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What is your current premium?
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Please list below, in paragraph form, any claims that you have made against an insurance carrier for the past 5 years:
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| 5. Do you sell any products? |
If so, please describe them:
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| 6. Do you install any of these products? |
If so, please describe and give the approximate annual revenue from this activity?
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