GENERAL INFORMATION:

1. Copies of current insurance policy declaration pages

2. Copies of any policy endorsements, amendments and special riders

3. Claims history "loss runs" for prior 3 years

4. Current and prior year premium

SPECIFIC PROPERTY INFORMATION:

1. Main address and address of other locations:
   
   
   

2. Premises Information:
      a. Building construction type:
      b. Description of surrounding buildings and any vacant land:
      
      c: Number of stories:
      d: Square feet:
      e: Year built:
       f: Year and type of renovations ex. wiring:
      g. Burglar alarm type:
      h. Security guards?:yes no
      i. Fire alarm type: 
      j. Fire protective equipment ex. sprinklers:

SPECIFIC LIABILITY INFORMATION:

1. Limits required:
      a. aggregate:
      b. products/operations:
      c. personal/advertising:
      d. each occurrence:
      e. fire damage:
       f. medical expense:

2. Basis for premium:
      a. Gross sales:
      b. Payroll:
      c. Area (sq. ft.):

3. For Contractors:
      a. Do you draw plans? yes no
      b. Any explosives?yes no
      c. Earth moving?yes no
      d. Subs. have lower ins. limits?yes no
      e. Require subs. have ins. certificate?yes no
       f. Equipment leased out?yes no

4. For Products and Operations:
   A: products handled:
        a: Annual gross sales: 
        b: Number units sold:          
        c: Expected life in market:  
        d: Intended use:
   B: Description of Operations:
        a: Install or Service ?
        b: R & D performed? yes no
        c: Guarantees/Warrantees?  
        d: Others' products repackaged?
   C: Misc. risk Provisions:
        a. Any hazardous materials? yes no
        b. Any parking facilities rented? yes no
        c. Any recreation facilities provided? yes no
        d. Any watercraft used? yes no
        e. Any medical facilities provided? yes no
         f. Any machinery rented to others? yes no

BUSINESS VEHICLE COVERAGE: (FOR EACH VEHICLE)

Limits of Coverage:
          Liability:
          Additional PIP:
          Personal Injury Protection PIP:
          Medical Payments:
          Uninsured Motorist:
          Underinsured Motorist:

Physical Damage:
         Comprehensive:
         Specific Comprehensive:
         Collision:
         Towing:

Coverage's:
        Hired/Borrowed (liability and physical damage)
        Non-owned

Description of Vehicles:
        Year:    
        Model:  
        Cylinders:
        Body/Type:     
        Vin/Serial Number:
        Where garaged:     
        Type of Use:       
        Cost when new:

Deductibles:

Driver Information:
       Name: (first/MI/last)
       Date of Birth: (mm/dd/yy)
       License type:
       License number:
       Moving violations:

Accidents:

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