PLEASE FILL OUT COMPLETELY.

First and Last Name of Contact
Phone Number                          
Fax Number                              
Email Address                           
Website Address                      
Company Name                        
Company Address                    
 

Nature of Business                    

Is this business a                       Corporation Partnership Individual Joint Venture Subchapter S Corp Not For Profit Org
Is this a new venture                No Yes
Number of employees              
Proposed Effective Date         
Federal Tax ID Number           
Date Business Started             
Estimated Annual Payroll         
Estimated Annual Sales           
Percent of operations subcontracted (if any)
Are certificates required from subcontractors
Building Owner or Tenant Owner Tenant
City Limits                         Inside Outside
Construction Type           Frame Veneer Joisted Masonry Light Non-Combustible Non-Combustible Masonry Non-Combustible Masonry Non-Com w/ Wind Resistive Roof
Number of Stories          
Year Built                        
Square Footage             
Is this a Multiple Occupancy Building      No Yes
Square Footage Lease Out (if any)      
Is there a vacancy on the ground floor No Yes
Value of Building (if building coverage is requested)
Business Personal Property Amount Requested      

Any Building Improvements             

What is to the right of the property

What is to the left of the property 

What is to the rear of the property

Is there a burglar alarm                       Yes No
If yes, what type of alarm                  Local Central Station Police Station
Alarm system installed & serviced by 
Is there a safe on the premises          No Yes
Is there a automatic sprinkler system Yes No

Current or Prior Carrier Information  

Describe any Claims or Losses          

GENERAL INFORMATION
Is the applicant a subsidiary of another entity         No Yes
Does the applicant have any subsidiaries                 No Yes
Is a formal safety program in operation                    No Yes
Any exposure to flammables, explosives, chemicals No Yes

Any policy of coverage declined, cancelled or non-renewed
during the prior 3 years                                             No Yes

Any past losses or claims relating to sexual abuse or molestation
allegations, discrimination or negligent hiring            No Yes

During last five years has any applicant been convicted of any
degree of the crime of arson                                    No Yes

Any uncorrected fire code violations                       No Yes

Any bankruptcies, tax or credit liens against the applicant
in the past 5 years                                                  No Yes

Has business been placed in a trust                        No Yes

Any medical facilities provided or medical professionals
employed or contracted                                          No Yes
Any exposure to radioactive/nuclear materials      No Yes
Any past/present involvement in hazardous materials No Yes
Machinery/equipment loaned or rented to others       No Yes
Any watercraft, docks, floats owned, hired or leased No Yes
Any parking facilities owned/rented No Yes
If so, is a fee charged for parking    No Yes
Recreation facilities provided           No Yes
Is there a swimming pool on the premises No Yes
Sporting of social events sponsored          No Yes
Any structural alterations contemplated   No Yes
Any demolition exposure contemplated    No Yes
Do you lease employees to or from other employers No Yes

Is there a labor interchange with any other business
or subsidiaries No Yes
Are day care facilities operated or controlled No Yes

Have any crimes occurred or been attempted on your premises
within the last three years No Yes

PLEASE ADDRESS ANY YES RESPONSES:

Please list any additional insured's you would like on the policy:

 

How would you like us to contact you Email Phone Fax

Comments: