APPLICATION

Name:
Business:
Business address:
Telephone number:
Fax:

*E-mail:
How long have you been in business:

For each business location please enter the following information

Building Location:
Masonry walls with:
Sprinkler System:
 Yes No
Metal walls with:
Wood Frame Construction
Approximate Square Footage:
How far are you from a fire department?
How far are you from a fire hydrant?
What value do you presently carry on your building?
What is the value of your business property?
What is the value of property belonging to others that you have on your premises:
Do you carry loss of business income if so what limit?
Do you have a separate limit on your computer equipment if so how much?
Do you own your building individually or are you a tenant?
If you own your building is it in
your name or the business name?
Approximate construction date of your building
Do you have an alarm system?
    Central Station
Yes No
What are your approximate gross receipts from manufacturing?
What are your approximate gross receipts from wholesale distribution if you are a supplier of glass ,tubing, or rods.
What are your foreign sales?
Tell us a little about your products you manufacture or the service you provide.
Do you ship via common carrier?
 Yes No
What is your payroll for :
    Manufacturing:
    Clerical Employees:
    Sales People:
Do you carry boiler and machine coverage for equipment breakdown and repair?
 Yes No
Do you have business umbrella liability policy:
 Yes No
    If so what limit:
Do you now have directors and office as liability insurance.
 Yes No
Do you now have employment practices liability.
 Yes No
How many vehicles do you have?
Do they travel within
50 miles
100 miles
250 miles
In the last 3 years
Have you had any property claims:
 Yes
Date
Amount paid
No
Have you had any liability claims:
 Yes
Date
Amount paid
No
Who is your current property and liability insurer:
When does your current coverage expire:
When is a good time to schedule a visit:
 Mornings:
Afternoons:
Is there anything special you would like us to know about you or your product?

* = Required

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