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Business Name
*
How is this business owned?
individual/sole proprietor
corporation
partnership
LLC
other
DBA?
FEIN or SS#
Type
FEIN
SS#
Contact Name
What is your location address?
*
What is your mailing address? (if different from business location)
Phone number (format 123456789)
*
Email
*
Web Site URL:
Describe Operations
Year business started
How many years have you been in this industry?
Number of full-time employees
Number of part-time employees
Annual Payroll
$
Annual Revenue:
$
Current Insurance Carrier
Effective Date?
What types of insurance do you need?
business owners policy (BOP)
general liability (GL)
commercial property
commercial auto
excess liability
workers comp
List claims with descriptions over the past 5 years
What are the hours of operation at your physical location?
Describe building to be insured
building square footage
Property Value?
Year built?
Roof – year last replaced
*
HVAC – year last replaced
*
Plumbing – year last replaced
Electrical – year last replaced
Gas Stations – # gas pumps
Gas Stations – Annual Gas Revenue
$
Gas Stations – Annual Liquor Sales
$
Gas Stations – Annual Merchandise Revenue (no gas/liquor)
$
Notes
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