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Firm Name Contact Name Street Address City     State AL AZ AR CO FL GA IL LA MD MN MO NM NY OH OK PA TN TX WI     Zip Telephone     Fax     E-Mail Underwriting Information 1. What is the nature of your business? 2. Is the business a Corporation, Partnership or Sole Proprietorship? 3. How many owners, partners and/or corporate officers are there? Owners:   Partners:   Corporate Officers: 4. How many employees are there? Full-Time: Part-Time: 5. What is the total annual payroll amount?         Owners, Partners or Corporate Officers:         Full-Time (not including owners, partners or corporate officers):         Part-Time (not including owners, partners or corporate officers): 6. a) What is the total annual gross revenue or sales?     b) Indicate % earned at this location: 7. What is the FEIN? 8. Have you filed bankruptcy within the past three (3) years? Yes No 9. Year business established. 10. How many years of industry experience does the owner of the business have? 11. On average, how many hours per day does your business operate? 12. Do you have ownership interest in any other business? Yes No 13. Do you lease employees to or from other employers? Yes No 14. Have any of your business insurance policies been declined, non-renewed or cancelled in the last three (3) years? Yes No Building & Property Information 15. a) What is the total square footage of the building you occupy?       b) Lease    Own       c) Are there other occupantes? Yes No 16. What is the total square footage of your business only? 17. How many stories is the building? 18. If it is two stories, what is the ground floor square footage? 19. What is the construction type? Select Brick Stone Frame Masonry Superior Log Cabin Frame-Stucco Masonry Veneer 20. What type of roof covering? Select Architectural shingles Asphalt/Fiberglassshingles Built-up/Tar and gravel Clay tile Concrete tile Corrugated steel Mineral fiber shakes Mission Tile Rock roof Roll roofing Rubber roof Slate Tin Wood fiber shingles Wood shake 21. a) What is the distance of the nearest fire hydrant? Ft.       b) What is the distance of the nearest fire department? Miles 22. How old is the building? 23. If the building is over 20 years old has the plumbing, electrical, roof and/or heating/AC been updated? Yes No       If so, when? 24. Does the building have interior automatic fire sprinklers? Yes No 25. a) Is there are theft alarm? Yes No       b) % of building protected 26. a) Is there a fire alarm? Yes No       b) % of building protected 27. a) Is there a sprinkler system? Yes No       b) % of building protected 28. Are there any property or general liability losses or claims in the last 5 years? Yes No 29. If yes, what is the date, amount paid and description of each loss or claim? Coverage Information 30. What is your current insurance company? 31. What is your expiration date? 32. Value of building, if owned? 33. Value of office contents? 34. Value of computer equipment & software? 35. How frequently do you deposit cash to the bank? 36. What is the maximum amount of money kept at your location overnight? Are there any questions, comments or additional coverage required? All information provided is confidential and will be used soley to obtain an indication for coverage. Coverage cannot be bound from this information sheet.