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Contact Information:

Underwriting Information:

Do the Applicant's Annual Receipts and/or combined building plus personal property values at any one location exceed $3,000,000?
Do the Applicant's Annual Receipts and/or combined building plus personal property values at any one location exceed $15,000,000?
At any location, does the Applicant both occupy a portion of the premises and lease 50% or more of the premises (excluding basement) to others?
What is the annual Payroll?
What is the percentage of subcontractors used?

Product Information:

Agency Name
Policy Product
Policy Program
Business Type
Full Time Employees
Part Time Employees
Year Business was Established or Acquired by Current Owner
Select Lines of Business to be Included in this Policy		Property
		General Liability
		Automobile
		Umbrella
Continuous Policy
Does applicant have any prior insurance?
Have there been any claims or occurrences within the last 5 years?
Do you have a hard copy loss runs?
Any other named insured with common majority ownership?
Is the primary location address different from the mailing address?

Line of Business #1

Line of Business #2

Line of Business #3

Has the applicant ever had coverage cancelled or non-renewed?

Cancelled

Non-Renewed

Policy Limit / Deductible Information:

Personal Property Valuation
Blanket Coverage		Building Blanket
Blanket Coverage		Personal Property Blanket
GL Occurrence/Aggregate Limit:

Products and Completed Operations Aggregate
Personal and Advertising Injury Limit
Tenants Legal Liability Limit
Medical Expenses

Property Location Schedule:

Address
Address 2
City
State
Zipcode
County
Territory
Protection Class
Interest Type
Is the distance to the fire station less than 5 miles?		Yes No
Is the property within 1000' of commercially navigable body of water?		Yes No
Detailed Description of Operations:

Building Schedule:

Building Limit
Personal Property Limit
Building Valuation
Construction Type
Year Built
Total Area - All Floors excluding Basement
Number of Stories
Number of Basements
Less than 1000' from hydrant?		Yes No
Does building have sprinklers?		Yes No
Fire Alarm Type
Burglar Alarm Type
Any loss payees/mortgagees?		Yes No

Additional Buildings:

Property Policy Options:

	Employee Dishonesty
	Signs

Supplemental Application Information:

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

Yes No

More Information:

Type anything that will help underwriting accept this risk

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