| Your
company name: |
|
| Mailing
address: |
|
| Are
you a sole proprietor:
Corporation:
Partnership:
Other:
|
| Years
in business: |
|
| Contact
person: |
|
| Phone
number: |
|
| Fax
number |
|
| Company
website address: |
|
| Contact
e-mail address: |
|
| Type
of business: |
|
| Description
of business/operations- Please describe in two or more sentences: |
|
| Actual
property address if different from mailing address: |
|
| Square
feet leased: |
|
| Approximate
age of building: |
|
| Are
you a tenant:
Or owner/landlord:
|
| Existing
insurance carrier name: |
|
| Existing
policy number (if any): |
|
| Any
losses last 5 years: Yes:
No:
, If yes, immediate coverage may not be available.
|
| Describe
losses: |
|
| Annual
sales: $ |
|
| Annual
payroll: $ |
|
| Driver's license numbers, names, of all outside
sales people or regular auto users if non-owned hired auto
coverage was purchased:
|
Building construction of the business location:
Frame:
Concrete:
Brick:
Other:
|
| Number
of floors in building: |
|
| Building
improvements if built prior to 1970 |
|
| -Estimated
wiring last updated: 19 |
|
| -Estimated
roof last replaced: 19 |
|
| -Estimated
plumbing last updated: 19 |
|
| Fire
Protection in your building: Extinguishers:
Sprinklers:
|
| Security protection: Burglar alarms: Yes:
No:
Dead bolts: Yes
No:
|
| If
burglar alarm, does it have a local bell:
Notify a central alarm company:
|
| Name
and address of your landlord/additional insured to be added
to the certificate if requested:
|
| Special
Instructions: |
|
| How
did you hear about ABC Insurance?
|
| For
your records, please print this page. When the application
is complete, click below to submit to ABC Insurance. |
|
|
