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Business Owners Package
Type of Business:  
First Name:
Last Name:
Business Name:
Mailing Address:
Mailing City:
Mailing State:
Mailing Zip Code:
Phone Number:
Fax Number:
E-Mail Address:
 

First and Last Name:
Property Address:
Property City:
Property State:
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:    
If Two Stories, Ground Floor Square Footage:  
Total Square Footage of Your Dwelling:  
 

  your request or     the form.

Construction Type:         
Roof Type:           
Roof Updated: yes no 
If Yes, Year Roof was Updated:
Protection Distance:        
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:   
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:       
 

  your request or     the form.

Theft Alarm:      
Fire Alarm:    
Losses-Claims in the last 5 years:              
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:        
Policy Deductible:        
Questions or Comments
to help the Agent:
 

  your request or     the form.