Fire Protection Insurance Questionnaire

Fire Protection Insurance Questionnaire
Applicant's Name:*
Address:*
Mailing Address
Address (cont):*
Mailing Address - continued
Contact:*
Email*
Telephone:*
Website
Fax:
Applicant is:

IndividualPartnershipCorporationLLCOther (Specifiy)Other
Current Carrier:
Expiration Date:
Limits: ($)
Premium: ($)
Deductible: ($)
Operations

1. Please include the following information with your submission for full consideration

a. A copy of: Inspection Form/Report, Contracts, Purchase Order, Invoice, Disabled System Notification, Sprinkler System Maintenance Agreement, Customer Agreement (plus any other documentation provided to customers).

b. Five years of loss runs and detailed account of open claims and any losses exceeding $10,000 paid.
2. How many years have you been in business and what is your experience in the industry?
3. Number of field personnel that have been with the company less than one year?
4. Please indicate number of employees:

Rows Full-Time Part-Time

Number
Note: Employees' include: Sole proprietors, Partners, Executive Officers, Seasonal employees, Part-time employees, Full-time employees.
5. Does your company operate under different company names?

YesNo
5a. If yes, please list names, operations and gross receipts for each name:
6. In what states do you conduct business?
7. Do you use subcontractors for fire suppression work?

YesNo
7a. What was the total cost of the subcontracted work?

Rows Last Year 5-Year Average

Total Cost
7b. Do you obtain a certificate of insurance from all subcontractors?

YesNo
7c. Are you added as an insured on the subcontractors' liability policies?

YesNo

Rows	Full-Time	Part-Time
Number

Rows	Last Year	5-Year Average
Total Cost

8. What types of accounts are serviced? (Total must equal 100% of operations.)

Rows	Percentage
8a. Installation for new construction
8b. Installation for existing construction (retrofit)
8c. Installation in occupied structures
8d. Maintenance and repair
8e. Inspection and testing

9. Approximately what percentage of jobs use CPVC pipes?
9a. How often is CPVC training completed?

10. Using your annual gross receipts, please estimate the income obtained from your client base:

Rows	Client Base Percentage
Commercial (Retail, Hotel/Motel)
Commercial (Apartments/Residential/Condo)
Institutional (Hospitals, Health Care, Assisted Living)
Industrial / Manufacturing - Installation in buildings < 50k sq. ft.
Industrial / Manufacturing - Installation in buildings > 50k sq. ft
High Hazard (Chemical Plants, Refineries, Nuclear, Railroad, Power Generation etc.)
Other (Describe in box below)
Total (Must equal 100%)

10a. Other types of client base

10c. Using your annual gross receipts, please estimate the income obtained from system types:

Rows	Systems Percentage
Wet Systems
Dry Systems
Pre-Action
Deluge
Special Hazard
Extinguishers – Hand Held
Pre-Engineered Systems
Other (Describe in box below)
Total (Must equal 100%)

10d. Other types of systems

11. What is the annual payroll and receipt breakdown?

Rows	Projected Amount	Year Prior	2 Years Prior	3 Years Prior
Total Receipts
Suppression System Payroll
Fire Extinguisher Payroll
Hood and Duct Cleaning Payroll
Alarm Payroll
Designer/Engineers Payroll
Other (Describe in box below)

11. Other Payroll Types
FIRE EQUIPMENT DEALERS
1. Are you a fire equipment dealer?

YesNo
1a. If yes, what are your annual gross sales?
1b. If yes, provide a complete list of supplies sold

Rows	Building Age	Building Construction	Building Limit ($)	Content Limit ($)
Building 1
Building 2

Rows	Year	Make	Model	Value to Insure For ($)
Item 1
Item 2
Item 3

Rows	Vehicle Make	Vehicle Model	Cost New ($)	Year
Vehicle 1
Vehicle 2
Vehicle 3

Rows	Amount ($)
Limit of Liability
Comprehensive Deductible
Collision Deductible