Person Completing this application

Name

Phone

E Mail

1

Legal Name of Business

2

Name of Insured /Owner

3

Exact Location Address

How long at this Location ?

4

Additional Locations

(use separate sheet for each location to be Insured)

5

Exact Nature of Business

Please be specific with details for each location.

6

Contact Person for Questions regarding this Application, Audit and Inspection (leave blank if its you)

7

E mail

8

Fax Number

9

     Phone Number

10

Web Site Address / URL

11

Date you started this business

Annual or Projected Gross Sales

$

12

Federal Tax ID #

State Tax ID #

13

Any Claims in the Last 3 yrs?

Y

N

If yes, the amount of loss $  

14

Loss Runs for the last 3 years are required

15

Amount of Personal Property Coverage desired

(furniture etc) Include List of Assets ( if possible ).

Amount of Personal Property Coverage desired (Computer equipment/electronic data ) Include List of Assets ( if possible ).

16

Sq. Ft. of entire Bldg

Sq. Ft. of area occupied by you

17

Year the building was constructed

Construction type, Frame,

Masonry, ?

18

Do you have an alarm ?

Y

N

Does the building have fire sprinklers?

Y

N

19

Number of Stories in the building

Do you own the building?

   Y          N

20

Type of Business on the right

21

Type of Business on the Left

22

Type of Business in the rear

23

Type of Business in the front

24

Present General Liability Carrier

25

Expiration date

Premiums at expiration date

26

(Circle) Liability coverage Limit

$ 1,000,000    or      $ 5,000,000     or  Other :

Want to increase or decrease to:

Would you like a competitive quotes for the following:

27

Errors and Omission (E&O) Coverage?

Y

N

Directors and Officers ( D&O ) Coverage?

Y

N

28

Commercial General Liability

Y

N

Health Insurance

Y

N

Additional Comments:

Commercial General Liability Questions

Yes

No

29

Any medical facilities provided or medical professionals employed or contracted?

30

Any exposure to radioactive/nuclear materials?

31

Do/have past, present or discontinued operations involve (d) storing, treating, discharging, applying, disposing, or transporting of hazardous material? (e.g. landfills, wastes, fuel tanks, etc.)

32

Any operations sold, acquired, or discontinued in last 5 years?

33

Machinery or equipment loaned or rented to others?

34

Any watercraft, docks, floats owned, hired, or leased?

35

Any parking facilities owned/rented?

36

Is a fee charged for parking?

37

Recreation facilities provided?

38

Is there a swimming pool on the premises?

39

Sporting or social events sponsored?

40

Any structural alterations contemplated?

41

Any demolition exposure contemplated?

42

Has applicant been active in or is currently active in joint ventures?

43

Do you lease employees to or from other employers?

44

Is there a labor interchange with any other business or subsidiaries?

45

Are day care facilities operated or controlled?

46

Any crimes occurred or been attempted on your premises within the last 3 years?

47

Does the businesses’ promotional literature make any representations about the safety or security of the premises?

48

Do you have any employee’s outside of California?

49

Do you want Directors and Officers Coverage?

50

Do you want Errors and Omission, professional Liability Coverage?

51

Do you want Product Completed and Operations Coverage?

   Commercial Insurance Application Questions

52

Is the applicant a subsidiary of another entity or does the applicant have any subsidiaries?

53

Is a formal safety program in operation?

54

Any exposure to flammable, explosives, chemicals?

55

Any catastrophe exposure?

56

Any other insurance with this company or being submitted?

57

Any policy or coverage declined, canceled or non-renewed during the prior 3 years? Not applicable in MO

58

Any past losses or claims relating to sexual abuse or molestation allegations, discrimination or negligent hiring?

59

During the last ten years, has any applicant been convicted or any degree of the crime or arson? (In RI, these questions must be answered by an applicant for property insurance, Failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one year of imprisonment.)

60

Any uncorrected fire code violations?

61

Any bank rupcies, tax or credit liens against the applicant in the past 5 years?

Name

Date of Birth

Soc. Sec #

Title

% of Ownership