This is a general business questionnaire. We will review the questionnaire before we contact you so we may better understand your business and your insurance needs.

Company Name:       

Your Name & Title:    

Address:                 

City:                         State:   Zip Code: 

County:                  

Work Phone:           Fax: 

E-Mail Address:      

Web Site:              

Age of Insured:       

Business Information

Type of Business Ownership

Select Corporation Limited Liability Corporation Individual Partnership Joint Venture Subchapter S Corp. Not For Profit Organization Other

Proposed Effective Date: Proposed Expiration Date:
Number of Years in Business:
Indicate Types of Coverages Applicable:

Property
Glass and Sign
Valuable Papers
Crime
Transportation
Equipment Floater
Installation/Builders Risk
Electronic Data
Commercial General Liability
Business Auto
Truckers
Garage and Dealers
Vehicle Schedule
Boiler and Machinery
Workers Compensation
Umbrella
Health

Number of Locations:

Nature of Business (Description of Operations)

Use this area for any special comments or coverages which need special attention.