Owner's Name :   

Business Name :  

Telephone number :  Fax number :  e-mail :

Business Address :

Type of Ownership :     Indivisual   Partnership   Corporation   Other

Description of your business :

New Venture ? :   Yes    No

If Yes, Number Of past experience : years

If No, How many years at present location : years

Current Insurance Company :

Current Insurance Policy No :         Expire date :

Loss History :   Yes   No

If yes , Explain

How much do you want to have General Liability Coverage
       $500,000        $1,000,000         $2,000,000      Other $

Annual Gross sale : $  

Annual Payroll :       $  

Do you need Liquor Liability?  :    Yes   No

Want to have Building coverage?   Yes   No    If yes, How much : $

Want to have Contents coverage? Yes   No   If yes, How much : $

Do you need Theft Coverage? :   Yes   No

Year built of the building ? :         Remodeling year ? :

Number of stories ?:  Total Area of store ?: S/F  Customer area ?: S/F

How many days open :  days a week  Business Open Hour :  From To

Have a Sprinkler ? : Yes   No

Have an Alarm ? :    Yes   No      If yes , Alarm Company name :

Tell me who is your right side :

                                Left side :

                               Rear side :

Landlord or Loss Payee required insurance ? :     Yes      No

   If yes, name :

          address :

Do you need workers compensation coverage? :   Yes      No

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