First Name (required):
Middle Name:
Last Name (required):
Other Named Insured:
Mailing Address:
Property Address (if different from mailing):
Telephone Number:
Email Address (required):
Website Address:
FEIN or Social Security #:
Retail %:
Wholesale %:
Importing %:
Type of Company: IndividualPartnershipCorporationJoint VentureSubchapter S CorporationNot For Profit OrganizationLLC
Date Business Started (mm/dd/yyyy):
# of Years in the Industry:
Current Insurance Carrier:
Policy #:
Premium:
Expired Date (mm/dd/yyyy):
Address:
Ownership: OwnerTenant
Nature of Business:
Year Built:
Number of Employees:
Percentage Occupied:
Square Footage:
Number of Stories:
Number of Apt Units:
Construction of the Building: BrickStuccoFrameOther
Burglar Alarm: NoneLocalCentral
Smoke Detector Alarm: NoneLocalCentral
Year of Update for Roof:
Year of Update for Electricity:
Year of Update for Heat:
Year of Update for Plumbing:
Building:
Contents:
Business Income:
Improvements & Betterments:
Deductible:
Employees:
#Males:
#Females:
Payroll:
Sales:
Name of Mortgagee or Landlord:
Glass Coverage: YesNo
Linear Feet:
Umbrella Policy Coverage: YesNo1 Million2 Million3 MillionOther *Please attach supplementary sheets for additional premises.
1. Is the applicant a subsidiary of another entity? YesNo If yes, please state reason
2. Does the applicant have any subsidiaries? YesNo If yes, please state reason
3. Is a formal safety program in operation? YesNo If yes, please state reason
4. Any exposure to flammables, explosives, chemicals? YesNo If yes, please state reason
5. Any catastrophe exposure? YesNo If yes, please state reason
6. Any other insurance with this company or being submitted? YesNo If yes, please state reason
7. Any policy or coverage declined, canceled or non-renewed during the prior 3 years? YesNo If yes, please state reason
8. Any past losses or claims relation to sexual abuse or molestation allegations, discrimination or negligent hiring? YesNo If yes, please state reason
9. During the last five years, has any applicant been convicted of any degree of the crime of arson? YesNo If yes, please state reason
10. Any uncorrected fire code violations? YesNo If yes, please state reason
11. Any bankruptcies, tax or credit liens against the applicant in the past 5 years? YesNo If yes, please state reason
12. Has business been placed in a trust? YesNo If yes, please state reason
Date of Occurence (mm/dd/yyyy):
Type/Description of occurence or claim:
Date of Claim (mm/dd/yyyy):
*Note: Five year loss history required. *Please attach supplementary sheets for additional premises.
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