---

Business Owners Package

---

---

Type of Business:   Type Of Business Malpractice; Ambulance Service Managed Care Errors and Omissions Managing General Agents Errors & Omissions Manicurists Liability Manufactured Homes Haulers Manufactured Homes Insurance Marina Operations and Boat Dealers Marine Cargo Insurance Marine Hull Insurance Marine Specialists Professional Liability Maritime Liability Marketing and Public Relations Firms Errors & Omissions Marketing Consultants Errors & Omissions Marriage & Family Counselors Martial Arts Liability Masseurs Errors & Omissions Material Handling Contractors Mediators/Arbitrators E&O Medical & X-Ray Labs. Professional Liability Medical Billing Companies Errors & Omissions Medical Diagnostic Centers (MRI Labs) E&O Medical Equipment Dealers Medical Equipment Manufacturers Medical Lab. Technicians Professional Liability Medical Personnel Service Agency Professional Liability Mental Health Clinics Professional Liability Messenger Services Metalworkers and Foundries Mexico Coverage Micro Brewery/Brew Pubs Midwives Professional Liability Miniature Golf Mining Operations; Coal Mining Risks and Equipment Mobile Home Dealers--Physical Damage & Liability Mobile Home Insurance Mobile Home Parks--Owners Liability Mobile Homeowners Package Policy Molestation Liability Moped Rental Insurance Mortgage Bankers & Servicing Agents Errors & Omissions Mortgage Brokers Errors and Omissions Mortgage Impairment Insurance Morticians Professional Liability Motor Home Rentals Motor Home/Travel Trailers (Commercial Use) Motor Homes Motor Scooter and Moped Rental Insurance Motor Scooter Insurance Motor Sports Liability Motor Truck Cargo Insurance Motorcycle & Motor Scooter Insurance Motorcycle Dealers--Physical Damage & Liability Motorcycle Rental Mountain Bikes/Dirt Bikes Mountain Climbing/Mountaineering Mountaineering Moving Companies Multiple Peril Crop Insurance Municipal and Public Entities Liability Museums Musical Instrument Floaters First Name: Last Name: Business Name: Mailing Address: Mailing City: Mailing State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Missouri Mississippi Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington West Virginia Wisconsin Wyoming Mailing Zip Code: Phone Number: Fax Number: E-Mail Address:

---

 

---

First and Last Name: Property Address: Property City: Property State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Missouri Mississippi Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington West Virginia Wisconsin Wyoming Property Zip Code: Property County: Please Describe the Nature of Your Business Number of Owners:

---

 

  your request or     the form.

---

Number of Employees: Payroll of Owners: Payroll of Employees: Total Annual Gross Receipts: Total Square Footage of the Building Your Business Is In: Square Footage Of Your Business Only: Current Insurance Company:

---

 

  your request or     the form.

---

Business License Number: License Type: Years of Experience: How Many Years Have You Operated This Business: How Many Stories: 1   2   If Two Stories, Ground Floor Square Footage:   Total Square Footage of Your Dwelling:

---

 

  your request or     the form.

---

Construction Type: Frame   Masonry Veneer   Masonry   Superior    Roof Type: Tile   Slate   Metal   Woodshake   Composite Material    Roof Updated: yes no  If Yes, Year Roof was Updated: Protection Distance: 1000 ft or less to a hydrant & 5 mi or less to a fire station   Over 1000 ft to a hydrant & 5 mi or less to a fire station   Over 5 & up to 10 mi to a fire station   Over 10 mi to a fire station   Is The Business In A Brush Area? yes no

---

 

  your request or     the form.

---

Is This Business Open 24 Hours A Day? yes no  Any Deep Frying (Food)? yes no  Is There Any Manufacturing, Mixing, Re-Labeling or Repackaging of Products? yes no  Is there Filing Of Propane Tanks? yes no  Is There Storage More Than 1500 Sq Ft? yes no

---

 

  your request or     the form.

---

If An Office Risk, Is E&O With 1 Million Admitted Coverage Carried? yes no  Are There Smoke Detectors At This Location? yes no  Smoke Alarm: yesno Fire Extinguisher: yesno  Deadbolts On All Doors? yesno Circuit Breakers: yes no

---

 

  your request or     the form.

---

Electrical Updated: Yes, Updated   No   Heating - Air Conditioning, Thermostatically Controlled?: yesno  Heating - Air Conditioning, Central? yes no  Plumbing Updated: yesno If Yes, Year Plumbing was Updated: Interior Automatic Fire Sprinklers:  None   Partial   Full

---

 

  your request or     the form.

---

Theft Alarm: None   Local   Central   Fire Alarm: None   Local   Losses-Claims in the last 5 years:  none   one   two   three   four   five    If yes, date, amount paid and description of each loss-claim Building Coverage: Other Structures Coverage: Business Contents Coverage:

---

 

  your request or     the form.

---

Loss of Use Coverage: Liability Limits Requested: $100,000   $300,000   $500,000   $1,000,000   Policy Deductible: 100   250   500   750   1000   2500   5000   Questions or Comments to help the Agent:

---

 

  your request or     the form.