BUSINESS OWNERS PROGRAM
Quote Request General Questionnaire

Name of Business:

Mailing Address:

City - St - Zip:

Owner Name:

Phone Number:

E-Mail Address:

Location address(es) (if different from mailing address above)?

Are there any businesses or business locations owned or operated that will not be specifically insured by this policy?

YES NO

When would you like this insurance to become effective?
(Note: cannot be a date in the past.)

Type of Ownership:

Corporation	Partnership or Joint Venture	Sole Proprietorship (Individual)
Limited Liability Corporation	Other:

What is your Federal Employer Identification Number (FEIN)? If you are a sole proprietor, please provide the owner’s Social Security Number.

Describe your business operations in detail including a description of goods or services provided. If applicable, indicate what percentage of your operation is retail, wholesale or manufacturing

Total Annual Gross Receipts/Revenues?

Current year (estimated) $

Previous year $

How long have you owned this business?

Is the business part of a franchise?

YES NO

Have there been any Property, General Liability or Products Liability losses, claims or suits within the last 3 years (even if not covered by insurance)? If yes, please describe.

YES NO

Date	Description	Total amount of loss

What actions, if any, have you taken to prevent similar losses:

Prior Business Insurance Carrier:

Will this policy need to cover any Loss Payees/Mortgagees/Additional Insureds?

YES NO

If yes, please list and describe each one below.

Location:
Name:
Address:
Interest:

Location:
Name:
Address:
Interest:

Location:
Name:
Address:
Interest:

Remarks