Contact
Name:
Number Full-Time Employees
Number Part-Time Employees
Years in Business:
Gross Annual Sales: $
Gross Annual Payroll: $
|
Describe the Nature of Business: |
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CURRENT INSURANCE INFORMATION
Company Name (not agency):
Policy Expiration Date:
Amount insured for: $
Years
insured:
Premium
Amount: $
Term:
If Other:
If
less than 3 years, prior company:
Prior
Losses/Dates (last 3 years):
Include Description, Date, Amount |
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CONSTRUCTION
Exterior:
Age of building:
Square footage of
your business area?
Square
footage of the entire building?
Roof:
Age of roof:
Stories in building:
Updated Heating or Plumbing?
Yes
No
Within 1000 feet of a fire hydrant?
Within 5 miles of a
fire station?
Central station
Burglar Alarm?
Automatic sprinkler
system covering 100% of your premises?
Please give any additional
comments.
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