| Contact Name * |
|
|
|
| E-Mail Address |
|
|
|
| Business Name |
|
|
|
| Mailing Address |
|
|
|
| Contact Phone |
|
|
|
| Fax If Applicable |
|
|
|
| Name Of Current Insurance Company |
|
|
|
| Policy Expiration Date |
|
|
|
| Current Coverages Needed: |
|
|
|
| *Commercial General Liability |
|
|
|
| *Commercial Umbrella |
|
|
|
| *Directors & Officers Liability |
|
|
|
| *Professional Liability |
|
|
|
| *Workers Compensation |
|
|
|
| *Disability |
|
|
|
| Number Of Full-Time Employees |
|
|
|
| Number Of Part-Time Employees |
|
|
|
| Business Address If Different Than Above |
|
|
|
| Number Of Years In Business |
|
|
|
| How Many Locations |
|
|
|
| Please Give A Brief Description Of Business And Clientele |
|
|
|
| Year Built Of Building Business Held In |
|
|
|
| Do You Own Or Rent Building Premises |
|
|
|
| Sprinklers For Fire Protection |
|
|
|
| Construction Type Of Business Premises |
|
|
|
| Number of Stories |
|
|
|
| Square Footage Of Business Premises |
|
|
|
| Burglar Alarm |
|
|
|
| Building Value-Excluding Land Value |
|
|
|
| Business Related Personal Property Value |
|
|
|
| Other Property Value(s) - Please Specify |
|
|
|
| Gross Sales Of Business Before Taxes |
|
|
|
| Annualized Payroll Excluding Owners |
|
|
|
| If Applying For Workers Compensation, Do You Want Owners Included in W.C. |
|
|
|
| Please Specify Annual Salary Of Owner(s) For W.C, or Disability |
|
|
|
| Cost Of Subcontracted Work If Any |
|
|
|
| Describe Any Claims You Had In The Last 5 Years |
|
|
|
| Additional Comments: |
|
|
|
|
|