Applicant Information:
Company Name:
Policy Effective Date:
Company Type:
Number of Employees:
Mailing Address:
Street:
City:
State:
Zip Code:
Web Site Address:
Contact Name:
Phone Number:
Email Address:
Inspection Contact Name:
Inspection Phone Number:
Inspection Email Address:
Accounting Contact Name:
Accounting Phone Number:
Accounting Email Address:
Year Founded:
Premises Information:
Location #1:
Check here if the same as the mailing address
Street:
City:
State:
Zip Code:
Year Built
Inside / Outside City Limits
Interest
Construction Type:
Sprinklers: Yes     No Sq. Footage at this location:

Location #1 Property Limits:
To determine limits, please complete the following:
Building: $
Personal Property: $
Computers $
Research & Development Property: $
Location #2:
Check here if the same as the mailing address
Street:
City:
State:
Zip Code:
Year Built
Inside / Outside City Limits
Interest
Construction Type:
Sprinklers: Yes     No Sq. Footage at this location:

Location #2 Property Limits:
To determine limits, please complete the following:
Building: $
Personal Property: $
Computers $
Research & Development Property: $
General Information:  Explain all YES responses in Remarks.
Is the applicant a subsidiary of another entity or does the applicant have any subsidiaries?
 
Is a formal safety program in operation?
Any exposure to flammables, explosives, chemicals?

 
Any catastrophe exposure?
 
Any other insurance with this company or being submitted?
 
Any policy or coverage declined, cancelled or non-renewed during the prior 3 years?
Any past losses or claims relating to sexual abuse or molestation allegations, discrimination or negligent hiring?
 
During the last ten years, has any applicant been convicted of any degree of the crime of arson?
 
Any uncorrected fire code violations?
 
Any bankruptcies, tax or credit liens against the applicant in the past 5 years?

General Liability:
Projected Sales
(U.S. plus Foreign):		 $
General Aggregate Limit: $
Each Occurrence: $
Products / Completed Operations: $
Personal Injury/Advertising: $
Medical Expense: $
Fire Legal Liability: $
Employee Benefit Liability: $
Loss History:
Concerning the coverage for which you are applying, have you had more than 3 losses in the last five years?

 
For losses you have had, please quantify and describe:
Have any of your losses exceeded $10,000?

 
Have you received any complaint letters from customers or competitors in the last three years?

 
If yes, please explain:
Comments:  
Additional Comments or Information: