Wholesalers & Distributers Supplemental Application
Is this questionaire for:  
New Business
Renewal Business
If "renewal" give current policy number:      
 Name
 Business Name
 Email Address
 Mailing Address
 Mailing Address
 City, State, Zip
 Phone Numbers  Home   Work 
    Fax   
How would you prefer to be contacted regarding your quote?   
If you would prefer to be contacted by phone, please let us know the best time to call:   
PRODUCT DESCRIPTION
1 Describe the type of products distributed by the applicant:
2 Does the applicant handle any foreign-made products? Yes    No
  If "yes", describe fully:
3 What percentage of gross annual sales are from the sales of foreign-made products?. %
4 What percentage of gross annual sales are made to the ultimate consumer? %
  What percentage of gross annual sales are made to others? %
5 Does the applicant operate out of his/her home? Yes    No
6 Can the applicant be considered a broker, manufacturer's representative or warehouser? Yes    No
  If "yes", explain:

7 		Describe the type and amount of inventory carried by the applicant:
SPECIAL OPERATIONS
  Is the applicant Involved in:
1 Installation, service or repair or products? Yes    No
2 Repackaging, modification, or labeling of products of others? Yes    No
3 Processing, manufacturing, bottling, packaging, etc. of his/her own products? Yes    No
  Explanation of "yes" answers:
OPTIONAL COVERAGES
    Off Premises Power Failure
    Commercial Property Protection Plus Endorsement
    Refrigeration Equipment Failure
COMMENTS
(Include any additional Information which may assist the underwriter in evaluating the applicant)
  Explanation of "yes" answers:
  Applicant's Signature:   _____________________________________________________________
  Date  
  Producer's Signature:   _____________________________________________________________
  Date