Rampart WURTH Liability Insurance Questionnaire

Name

First NameLast Name

Business Name

Property Address*

Street Address

Street Address Line 2

CityState

Zip Code

Is this also the mailing address?*

Mailing address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Occupation*

Social Security Number*

Email*

example@example.com

Phone Number*

Please enter a valid phone number.Format: (000) 000-0000.

Date of Birth*

Date

Do you have a spouse and/or co-applicant?*

Spouse/Co-Applicant Name*

First NameLast Name

Spouse/Co-Applicant Occupation*

Spouse/Co-Applicant Date of Birth*

Date

Spouse/Co-Applicant Social Security Number*

Current Insurance Company

Expiration Date/Expected Closing Date*

Date

Requested Coverage Limit*

Occupancy*

If rented to others, Short or Long term rental?*

How many units*

Is there a pool?*

If yes, is pool fenced?*

Does pool have diving board or slide?

Is there a trampoline?*

Do you have a dog?*

Dog breed?*

Has there been any liability claims in the past 3 years?*

If yes, has the claim been finalized or closed?*

Approximate amount of settlement payment*

Any location owned by an LLC or Trust?*

List all Entity Members:

Purpose of the formation of the entity:

If Other, please explain

Has the purpose of the entity changed since it's formation?

Within the past five years, has the entity engaged in any form of business or owned any real estate for business purposes?

In the past five years, has the entity been subject any kind of litigation?

Does the entity have any employees?

Provide additional information to any "Yes" response(s):

List any additional exposures, real estate, personal property or assets owned, in whole or in part, by this entity:*

If yes, Percent:

If yes, Usage/Occupancy:

Any Vacant Land?*

If Yes, how many acres?

Any additional locations to include?

Location # 1
Address:   Street Address   Address Line 2   City   State   Zip

Number of units:   number of units

Occupancy:      Owner   Rented to others

If Rented to others:

Location # 2
Address:   Street Address   Address Line 2   City   State   Zip

Number of units:   number of units

Occupancy:      Owner   Rented to others

If Rented to others:

Location # 3
Address:   Street Address   Address Line 2   City   State   Zip

Number of units:   number of units

Occupancy:      Owner   Rented to others

If Rented to others: