THIS FORM IS ONLY FOR A BUSINESS LOCATED IN THE STATE OF TEXAS. IF OUTSIDE OF TEXAS, PLEASE CONTACT JAMES ZANDER DIRECTLY.
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 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 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 Is a formal safety program in operation 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:
