SECTION I. General Information:
1. Name of Organization
*
2. Location Address
*
Physical Address
3. Mailing Address (if different from location)
4. Description of Operation (including any activities, programs or services provided)
*
5. Purpose and Mission of the Organization
6. Number of Years in Operation
7. Does the organization have tax exempt status as defined by the I.R.S.?
Yes
No
8. E mail Address
*
example@example.com
9. Website Address
10. Inspection Contact First and Last Name
*
11. Inspection Contact Phone
*
Format: (000) 000-0000.
12. Functioning Smoke Detectors in all common areas:
*
Yes
No
13. Annual Revenues
14. Number of Members
*
SECTION II. Businessowners Liability:
A. General Liability:
15. Limit of Coverage Selected:
$300,000/$600,000
$500,000/$1,000,000
$1,000,000/$2,000,000
$1,000,000/$3,000,000
16. Any products or concessions sold? If so, please products and annual sales amount.
17. Have there been any general liability claims in the last 5 years? If so, please provide details. (include dates and amount paid)
18. Additional Insured's to be included (List name, address and relationship to the applicant)
B. Property (Complete this section for location to be insured):
19. Address
19. Building Address (if different than above) Only complete this section if you need insurance for property
Street Address Line 2
City
State / Province
Zip code
20. Building Value (at 80% Coinsurance/Replacement Cost)
What is your building value
21. Personal Property Limit (at 80% Coinsurance/Replacement Cost)
What is your contents value
22. Total Square Footage of building
23. Building Interest: (please check one):
Owner
Tenant
24. Building Age
*
Year Built
25. Roof Age
*
Year Updated
26. Type of roof?
Flat
Wood Shake
Shingle
Metal
Tile
Slate
Other
27. Building Construction (please check one):
Frame
Joisted Masonry
Non-Combustible
Masonry Non-Combustible
Fire Resistive
28. Protection Class (1 10)
29. When were the following last updated? (Year)
Electrical
Year Updated
Heating
Year Updated
Plumbing
Year Updated
30. Is all electrical wiring on functional and operational circuit breakers?
Yes
No
31. Is there any Aluminum Wiring or Knob and Tube Wiring?
Yes
No
32. Type of Burglar Alarm
Central (monitored by alarm company)
Direct (reports directly to city/county emergency services, 911)
Local (audible alarm at location)
None
33. Type of Fire Alarm
Central (monitored by alarm company)
Direct (reports directly to city/county emergency services, 911)
Local (audible alarm at location)
None
34. Type of plumbing?
PVC/Plastic
Copper
Iron
Lead
Galvanized
Other
35. Loss Payee or Mortgagee Clause (if applicable)
36. Have there been any property claims in the last 5 years? If so, please provide details.
C. Other Coverages
37. Do you need Special Event Coverage?
Yes
No
38. If you need Special Event Coverage, do you want to include it in your general liability policy annually or for each event separately?
39. Will you serve alcohol at any events?
40. Do you need a Surety Bond?
*
Yes (please answer the questions below)
No
41. Coverage Amount
$5000
$10,000
$25,000
$50,000
$100,000
42. Number of Officers Covered? (should include top officers and anyone handling funds)
43. Any prior surety bond claims? If so, please give details.
44. What term bond?
1 Year
2 Year
3 Year
We are a full service insurance agency. Do you need any other insurance products?
Business Auto
Life Insurance
Home Insurance
Personal Auto
Other
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