General Information - BOP

Name of Business     D/B/A 

                         Year Est.                                                                     Federal Identification Number   -  

Address    

City                 State AL AK AR AZ CA CO CT DE FL GA HI IO ID IN IL KA KY LA MA MD ME MI MN MO MS MT NC ND NE NH NJ NM NV NY OH OR OK PA RI SC SD TN TX UT VA VT WA WI WV WY               Zip

Business Phone#   --                        Business Fax #  --                  

Email Address  

Website

Contact Name   Best Time to Contact Before 9:00am EST 9:00am - 11:00am EST 11:00am - 1:00pm EST 1:00pm - 3:00pm EST 3:00pm - 5:00pm EST After 5:00pm EST

Type of Business

Description of Operations (Please give a complete description):

Prior Policy Information (If new Business, just type "new" in for prior carrier)

Prior Carrier (Type "None" if  no prior in last 18 months)    Expiration Date                                     How Many Years of Continual Coverage New Business Less than a Year 1 Year 2 - 3 years 4 - 5 Years 5 - 10 years 10 or More Years   Was Policy Cancelled or Non Renewed    Yes   No                                 Has your Company Ever Had A Claim (if yes; please describe loss(es) below) Yes   No

                      Please list as much about the claim as possible, including dates, names, and costs of injury. This will save us time while we are waiting                                                                                 for your loss runs from your prior or current insurance carrier.

Prior General Aggregate Liability Limits or Limit Requested   $600,000 / $300,000 $1,000,000 / $500,000 $2,000,000 / $1,000,000 $3,000,000 / $2,000,000 $5,000,000 $10,000,000 $15,000,000 $25,000,000 Over $25 Million      Deductible Requested   $1000 / $1,000 Wind $1,000 / 2% Wind $2,500 / 2% Wind $5,000 / $5,000 Wind $5,000 / 2% Wind $1,000 / 3% Wind $2,500 / 3% Wind $5,000 / 3% Wind $1,000 / 5% Wind $2,500 / 5% Wind $5,000 / 5% Wind $10,000 / 5% Wind

Commercial General Liability

What are your Total Gross Receipts per Year  

General Aggregate Liability Limits     $600,000 / $300,000 $1,000,000 / $500,000 $2,000,000 / $1,000,000 $3,000,000 / $2,000,000 $5,000,000 $10,000,000 $15,000,000 $25,000,000 Over $25 Million

Do you Handle Hazardous Materials Yes  No

Do you make Written Guarantees or Warrantees Yes   No  

Have you ever claimed bankruptcy Yes  No

Do you have Sub-Contractors  Yes   No

If Yes, Do you make your Sub-Contractors carry the same Liability Limits  Yes   No

Do you require Certificates of Insurance from all Sub-Contractors  Yes   No

Property Coverage

How Many Buildings or locations are to be insured 1 2 3 4 5 6 7 8 9 10 or More

Value of the Property to be Insured (Total of all buildings to be insured ; if you rent or lease, type in "Lease".)

Value of Contents to be Insured (This should include: Furniture, Fixtures, Equipment, etc...)  

Square Feet of Buildings  

Are You in a Flood Zone Yes   No

Are any of the buildings to be Insured on Piers, Pilings, Wharfs, or over water Yes   No

Employee Information

How Many Employees does your company have  

What your Total Annual Payroll for Labor  

Do you want to cover your employee's payroll in the event of Business Interruption Yes  No

Do you ant coverage for Business Income Loss in the event of Business Interruption Yes   No

If Yes, What is your gross income monthly

How long do you want the payments paid for 1 Month 2 Months 3 Months 4 Months 5 Months 6 Months 1 Year Total Restoration Period

Elimination Period (Length of time before you want payments to start. The Longer the less expensive the premium.) 1 Month 2 Months 3 Months 4 Months 5 Months 6 Months 1 Year Total Restoration Period