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General Information Business Name Contact Name Address Phone City Fax MA AK AL AR AS AZ CA CO CT DC DE FL FM GA GU HI IA ID IL IN KS KY LA ME MD MH MI MN MO MP MS MT NC ND NE NH NJ NM NV NY OH OK OR PA PR PW RI SC SD TN TX UT VI VT VA WA WI WV WY State Email Zip Code Web URL If Any Type Of Business Please provide a brief description Type Manufacturing Construction Retail/Wholesale Mobil Home Park Condominiums Apartments Shopping Center School Gas Station Garage Restaurant Hotels Other How long has this company been operating? Who is your current insurance carrier? Have you had losses or claims in last 3 years? Individual DBA Partnership Corporation General Liability Questions Number of Employees Number of Owners Payroll for Employees Annual Gross Receipts $300,000 $500,000 $1,000,000 $2,000,000 Liability Limit No No Yes Employee Benefit Coverage? Yes Employee Benefit Coverage? Property Details Building Owned Leased Construction Type Block Frame Non-Combustible No Sprinklers Sprinklers Value of Building (if owned) Square Footage Age of Building Value of Contents on Premise Value of Property off Premise No Ordinance of Law Yes Deductible No Coverage $250 $500 Vehicles No Yes Vehicle # 1 Make/Model Year Value Comprehensive Yes Collision Yes No No Vehicle # 2 Make/Model Year Value Comprehensive Yes Collision Yes No No Vehicle # 3 Make/Model Year Value Comprehensive Yes Collision Yes No No Vehicle # 4 Make/Model Year Value Comprehensive Yes Collision Yes No No Liability Limit Any tickets or Accidents $100,000 $300,000 $500,000 $1,000,000 Number of Drivers Yes Please describe if any No Workers Compensation Coverage in Other State Umbrella Coverage Limit 100/500/100 500/500/500 500/500/500 1000/1000/1000 Yes Yes Total Payroll No No How did you hear about us? Enter Additional Information here if not covered above