Operation Information Description of Operation:
Annual Receipts................. Annual Payroll.................... Number of Owners, Partners or Officers...... Number of Full Time Employees................ Number of Part Time Employees................
Location of Business
Address...... City State Zip
Business Occupancy. Office or Storage Construction..... Frame or Masonry
Square Footage.....................
Value of Building (if owned).....
Year Building Constructed.......
Fire or Burlar Alarms.............
Sprinkler System...................
Value of Contents.................. Value of Tools & Equipment....
Loss History (List all losses in last three years)
Select if none Date........Description.........Amount
Have you had previous insurance? Yes No If yes, how many years?......... When does it expire?..............
Comments
Please Note: Insurance coverage cannot be bound without a written binder from our office.
