| Underwriting Information: |
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Describe IN DETAIL,
Your Business Operations: |
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| Ownership & Payroll Data: |
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List Employee's Annual Payroll Here (if none, enter $0):
| $
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Insert # of
Employees here:
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| Location & Sales Information: |
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Insert Annual Gross Revenues from this operation here:
| $
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Square Footage of office or business location:
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Type of Building (wood frame, concrete, etc.):
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Number of Stories:
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Are there other business/residences in this building (describe)?:
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Describe safety features (alarm, sprinklers, fire protection, etc):
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| Coverage Desired: (Check One Please) |
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The Coverage I Am Looking For:
Liability Only
Liability & Business Contents
Liability, Building & Contents Coverage
A Package Policy Including the Above,
Plus Miscellaneous Coverages
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NOTE: Don't worry if you are not exactly sure about
coverage type. We will suggest the best coverage for you - just try to tell us what you are looking for!
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Liability Coverage:
($300,000, $500,000, $1 Million, etc.)
| $
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Business Contents Coverage:
(The amount of your personal business property)
| $
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Building Coverage:
(The amount of building coverage if you own your bldg.)
| $
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Miscellaneous Coverage:
(List any special coverage peculiar to your business, such as Garagekeepers Legal, Loss of Earnings, Valuable Papers, etc.)
| $
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