Underwriting Questions
Property Address:
Property City:
Property State:	Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Dist of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Missouri Mississippi Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington West Virginia Wisconsin Wyoming
Property Zip Code:
Property County:
Please Describe the Nature of Your Business
Number of Owners:
Number of Employees:
Payroll of Owners:
Payroll of Employees:
Total Annual Gross Receipts:
Total Square Footage of the Building Your Business Is In:
Square Footage Of Your Business Only:
Current Insurance Company:
Business License Number:
License Type:
Years of Experience:
How Many Years Have You Operated This Business:
How Many Stories:	1   2
If Two Stories, Ground Floor Square Footage:
Total Square Footage of Your Dwelling:
Construction Type:	Frame   Masonry Veneer   Masonry   Superior
Roof Type:	Tile   Slate   Metal   Woodshake   Composite Material
Roof Updated:	yes no
If Yes, Year Roof was Updated:
Protection Distance:	1000 ft or less to a hydrant & 5 mi or less to a fire station   Over 1000 ft to a hydrant & 5 mi or less to a fire station   Over 5 & up to 10 mi to a fire station   Over 10 mi to a fire station
Is The Business In A Brush Area?	yes  no
Is This Business Open 24 Hours A Day?	yes  no
Any Deep Frying (Food)?	yes  no
Is There Any Manufacturing, Mixing, Re-Labeling or Repackaging of Products?	yes  no
Is there Filing Of Propane Tanks?	yes  no
Is There Storage More Than 1500 Sq Ft?	yes  no
If An Office Risk, Is E&O With 1 Million Admitted Coverage Carried?	yes no
Are There Smoke Detectors At This Location?	yes no
Smoke Alarm:	yes no
Fire Extinguisher:	yes no
Deadbolts On All Doors?	yes no
Circuit Breakers:	yes no
Electrical Updated:	Yes, Updated   No
Heating - Air Conditioning, Thermostatically Controlled?:	yes no
Heating - Air Conditioning, Central?	yes no
Plumbing Updated:	yes no
If Yes, Year Plumbing was Updated:
Interior Automatic Fire Sprinklers:	None   Partial   Full
Theft Alarm:	None   Local   Central
Fire Alarm:	None   Local
Losses-Claims in the last 5 years:	none   one   two   three   four   five
If yes, date, amount paid and description of each loss-claim

Coverage Information Section
Building Coverage:
Other Structures Coverage:
Business Contents Coverage:
Loss of Use Coverage:
Liability Limits Requested:	$100,000   $300,000   $500,000   $1,000,000
Policy Deductible:	100   250   500   750   1000   2500   5000
Questions or Comments to help the Producer: