Producers Information:

Your email address:

Basic Information:

Contact Name:
Date of Request:
Date Policy Expires:
Date Response Needed:

If new in your business, how much experience do you have in this type of business?

Please describe the nature of your business:

# of Owners/ # of Officers:
/

Current insurance company?

Prior insurance company, if known?

Any losses paid on your behalf in the last 5 years?
yes no

Please provide us with some information on your claims history:

	Claim #1	Claim #2	Claim #3
Date of claim:
How much was paid?
Type of loss:

Schedule Of Hazards:

Location #	Classification	Gross Sales	Area
1 2 3
1 2 3
1 2 3
1 2 3
1 2 3
1 2 3

Payroll:

Location #	Duties/Classification	Payroll/Class	# of Employees/Class
1 2 3
1 2 3
1 2 3
1 2 3
1 2 3
1 2 3

Do you provide benefits to your employees?
yes no

What type?

Annual sales (each location):
Location #1: IE: $97,435 should be typed in as 97435. Numbers only.
Location #2: IE: $97,435 should be typed in as 97435. Numbers only.
Location #3: IE: $97,435 should be typed in as 97435. Numbers only.
Total at all locations (if more than 3 locations):

Property Information:

	Location #1	Location #2	Location #3
Building coverage limit:
Contents coverage limit:
Tenant improvements limit:
Value of outdoor signs:
Awnings:
Fences:
Value of property of others which you are responsible:
Building fire resistive:	yes no	yes no	yes no
Building non-combustible:	yes no	yes no	yes no
Building joint masonry:	yes no	yes no	yes no
Building wood frame:	yes no	yes no	yes no
Number of stories:
Ground floor area:
Basement:	yes no	yes no	yes no
Year of construction:
Sprinkler system:	yes no	yes no	yes no
Central fire/Burglar alarm:	yes no	yes no	yes no
Year updated wiring:
Year updated plumbing:
Year updated HVAC:
Year roofing replaced:

If building owner, name and business specialty of EACH tenant:

Total value of monthly rent:

Computer coverage (hardware/software each location)
Location #1:
Location #2:
Location #3:

Do you lease or rent tools or mobile equipment that are used away from your permises?
yes no

What is your maximum exposure per tool?

What is your TOTAL exposure if ALL tools are stolen in a single loss?

Employee dishonesty coverage limit?

ERISA Limit?

Desired general liability limits? (We recommend AT LEAST $1,000,000)

Workers compensation #:

Federal ID Tax #:

Automobile Information:

	Vehicle #1	Vehicle #2	Vehicle #3	Vehicle #4	Vehicle #5
Year:
Make:
Model:
Vin #:
Use of vehicle:
Garaging location:
Comprehensive deductible:
Collision deductible:

	Driver #1	Driver #2	Driver #3	Driver #4	Driver #5
Name:
D.O.B.:
DL #:
SS #:

What limit of Liability are you requesting?

What limit of Excess Liability are you requesting?

Would you like Flood Coverage?
yes no

Would you like Earthquake Coverage?
yes no

Please include other information such as any out of state exposure, any WC exposure, any carrier preference, etc...

If you are and Apartment Owner, please complete the following:

Number of total units:

What is average % of occupancy:

Is there any other type of occupant (retail, office, restaurant):
yes no
if yes, please describe:

Was building originally built as apartment or converted?
yes no
Are the smoke detectors hard wired?
yes no
What year?

If you own or operate a Restaurant, please complete the following:

Do you have a UL 300 wet chemical fire suppression system?
yes no
Do you have current contract for Hood and Duct Cleaning from outside contractor?
yes no
How often is it professionally cleaned?

In the event of an extended power outage, what is the value of inventory you would lose?

What are your receipts for annual sales of beer, wine and liquor?

Do you do outside catering?
yes no
What is the annual revenue for catering?

Do you provide entertainment?
yes no
If yes, please describe:

Do you have "happy hours"?
yes no
If yes, please describe:

If you Own or operate a Garage or Body Shop, please complete the following:

Number of service or work bays:

Maximum Total value of customer vehicles INSIDE THE BUILDING:

Maximum Total value of customer vehicles OUTSIDE THE BUILDING:

What damage deductible do you desire on customers cars:
500 1000 2500
Do you provide towing services:
Incidental to my business Contract towing for municipalities, or other commercial ventures
Annual receipts from towing operation:

Total number of employees: