ABOUT THE BUSINESS
Name of Business:
Type of Business:
Description of Business:
Year Started:		Years experience in industry:
	Space Occupied (sq feet): (location 1)
	Space Occupied (sq feet): (location 2, if any)
	Total building space (sq feet): (location 1)
	Total building space (sq feet): (location 2)
	Stories (location 1): 0 1 2 3 4 Stories(location 2): N/A 0 1 2 3 4
	Year Building Built:
Full Time Employees	Part-Time?
	Number of Partners/Execs:
Smoke Detectors:	Yes No    Sprinklers: Yes No
Tax ID #
Industry Code	(if known)
Liability Limits:	$ CHOOSE ONE $500,000/$1,000,000 $1,000,000/$2,000,000 $2,000,000/$4,000,000 OTHER - ENTER TO RIGHT
Gross Receipts:	$
Annual Income:	$
Annual Payroll:	$
	Yes CHOOSE ONE No      Any cooking on premises?
	CHOOSE ONE Yes No      Any roofing?
	CHOOSE ONE Yes No      Is this a franchise operation?
	CHOOSE ONE Yes No      In an enclosed shopping mall?
	CHOOSE ONE Yes No      Any chemical exposure?
	CHOOSE ONE Yes No      Any armed security guard or dogs?
	CHOOSE ONE Yes No      Any work performed above 2 stories?
Other:	Safe on Premises? Yes CHOOSE ONE No
	Prior losses or claims? CHOOSE ONE Yes No
	Building Security System? CHOOSE ONE YES - LOCAL ALARM YES - CALLS POLICE YES - CALLS CENTRAL STATION
***	Do you currently have insurance (if yes, with what carrier?
	Current Premium:   Annualy Monthly
	Do you have any other information about your business, or comments that you would like to share? Please place special requests here, such as extra coverage for special items..