Business Operations

Age of Business: Years       How long under current ownership?    Years

Experience or Training of current ownership:

Gross Sales $

Annual Payroll by Class:
1: $
2: $
3: $
4: $
5: $

Current Carrier: Premium:$   Due Date:   MM/DD/YYYY

3 Year Loss History:

Protective Devices

Burglar Alarm: Yes No Central Local

Sprinkler System: Yes No   Closest Hydrant: Feet

Surge Suppression: Yes No    Secondary Power Supply: Yes No
 

Property Coverages

Building Limit: $

Business/Personal Property: $      Deductible: $ 250 500 1000 2500

Property of Others:$  Deductible: $ 250 500 1000 2500

Tools or Mobile Equipment: $  Deductible: $ 250 500 1000 2500

Other: $    Deductible: $ 250 500 1000 2500

List any other Coverages you may need:

Year Your Property was Last Updated:
Roof:   Plumbing:   Heat:    Electrical: 

Liability Coverage

General Liability per Occurrence:  $   Aggregate: $  

Occurrence Yes No   Claims Made: Yes No   RetroDate:

If claims made have you ever had a lapse in coverage? Yes No

Hired and Non-owned Limit:  $

International Coverage? Yes No

Number of Additional Insureds :

List other special Coverages you require:

Business Auto Information

If your business demands the use of more than five vehicles, we have markets for it as well.  Please call our office and ask for a business insurance consultant to discuss your insurance program.

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