Personal Information
*First Name
*Last Name
Business Name
Street Address
City/St/Zip
*Phone Number
Alternate Number
*Email Address
Underwriting Information
What is the nature of your business?
Number of Owners
Number of Employees
Payroll of Owners
Payroll of Employees
Total annual gross receipts
Total annual hard liquor receipts
Total annual beer and wine receipts
Total annual food gross receipts
Business License Number
License Type
Years of experience
Years operated under current name
Is this business open 24 hours a day?
Yes No
Is there filling of propane tanks?
Yes No
Please describe ANY unusual exposures:
Building and Property Information
Property Street Address
Total square footage of the building your business is in
Total square footage of your business only
Total square footage of the customer area only
How many stories is it?
If two stories, what is the ground floor square footage?
What is the construction type?
-Select- Brick Stone Frame Masonry Superior Log Cabin Frame-Stucco Masonry Masonry Veneer
What type of roof covering?
Was the roof updated?
Yes No
If yes, what year?
What is the distance to fire protection?
-Select- 1000 ft or less to hydrant and 5 mi or less to fire station Over 1000 ft to hydrant and 5 mi or less to fire station Over 5 and up to 10 mi to fire station Over 10 mi to fire station
Is the business in a brush area?
Yes No
Do you have a storage area more than 1500 sq. ft?
Yes No
Are there smoke detectors at this location?
Yes No
Are there fire extinguishers?
Yes No
Are there deadbolts on all doors?
Yes No
Are there circuit breakers?
Yes No
Is the electrical updated?
Yes No
Is the heating / air conditioning thermostatically controlled?
Yes No
Is the heating / air conditioning central?
Yes No
Has the plumbing been updated?
Yes No
If yes, what year was the plumbing updated?
Does the building have interior automatic fire sprinklers?
Yes No
Is there a theft alarm?
Yes No
Is there a fire alarm?
Yes No
Is the parking lot under your protection?
Yes No
Miscellaneous and Claims Information
Were there any losses or claims in the last 5 years?
Yes No
If yes, what is the date, amount paid and description of each loss or claim?
Current Insurance Company
How much are you paying now?
What is the renewal date?
Has insurance ever been cancelled?
Yes No
If yes, describe
Have you ever had regulatory violations or citations?
Yes No
If yes, describe
Are employees trained on how to handle minors or intoxicated customers?
Yes No
If yes, describe
Coverage Information
What building coverage is requested?
What other structures is requested?
What business contents is requested?
What is the loss of use coverage requested?
What is the liability limit requested?
-Select- 100,000 300,000 500,000 1,000,000
What is the policy deductible requested?
-Select- 250 500 1,000 2,500
What is the business personal property (contents) limit requested?
What is the contents deductible requested?
-Select- 100 250 500 750 1,000 2,000 5000
Questions or Comments
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