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| Underwriting Information: |
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| Operations Data: |
Describe IN DETAIL,
Your Business Operations: |
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| Ownership & Payroll Data: |
List Employee's
Annual Payroll Here
(if none, enter $0): |
$ |
Insert # of
Employees here: |
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Number of
Employees driving
vehicles at work: |
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Number of
Employees
that do NOT
drive at work: |
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Number of
Employees driving
vehicles over 25
years old: |
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Number of
Employees
driving vehicle
over 72 years
old: |
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| NOTE: List any drivers MVR Activity in remarks (tickets, accidents, etc.) |
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| Location & Sales Information: |
Insert Annual Gross
Revenues from this
operation here: |
$ |
Square
Footage of
office or
business
location: |
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Type of Building
(wood frame,
concrete, etc.): |
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Number of
Stories: |
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Are there other
business/residences
in this building
(describe)?: |
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Describe
safety features
(alarm,
sprinklers, fire
protection,
etc): |
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Provide breakdown percentages:
Passenger %
Truck %
Off-the-Road % |
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| Coverage Desired: (Check One Please) |
Limits of Coverage I am Interested In:
$100,000
$300,000
$500,000
$1 Million
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| Medical Limit ($1000 or $5000): |
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Limit of business property needed:
$ property coverage |
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Limit of open lot (vehicles held for sale) coverage needed:
$ vehicle values |
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Limit of garagekeepers coverage (value of vehicles in possession):
$ garagekeeper limit |
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| Comp & Coll. Deductibles ($250, 500, 1000 ): |
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| NOTE: Don't worry if you are not exactly sure about coverage type...
we will suggest the best coverage for you - just try to tell us what you are looking for!
(If we need more info. we will let you know.) |
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| Comments/Remarks: |
