Do you currently have Insurance?  Yes No

Are you being Cancelled or non renewed? Yes NO

If yes, What was the Reason?

Who is you current insurance carrier (Not agency Not agency Name)?

When does your insurance Expire?

What is you current premium?

Number of claims in the past 3 years 0 1 2 3 4

What is the name of your business?

Business Description (Please be as detailed as possible)

Business Entity is a(n)? Individual Partnership LLC Other Corporation

How many owners (that are involved in daily operations) 1 2 3 4

What is your estimate for employee payroll for the year? (Excluding owners and clerical)

Liability

What is you current Liability Limit $500,000 $1,000,000 $2,000,000 Other

If other please specify

Property

What are your  Contents (Business Personal Property Insured For)

Location

Business Address

Mailing Address (if Different)

Approximate Square Footage

Do you own the building building where your business is located? Yes No

If yes what is the current amount the building is insured for

What year was the building built?

What is the overall condition of the building? Excellent good poor

Has it been completely updated in the past 15 years Yes No

Contact Info

Name of contact person

Business Phone Number

Business Fax Number

Best number to reach you in case we need additional information

You Email Address

Preferred Method of Contact Phone Fax Email

Any questions or comments you may have