Name:
Address:
Individual SS#:
Corporate Tax ID:
Phone Number:
Contact for Inspection:
Nature of Business:
Years of Operation:
Prior Insurance & Policy Number:
Loss History (3 Years):
Is this a new venture:
Yes
No
Years in Business:
Hours of Operation:
Number of Employees:
Annual Payroll:
Annual Sales:
Property (Construction Type):
Brick
Frame
Year Built:
Roof:
Flat
Pitched
Number of Stories
Heating Type:
Oil
Gas
If Oil, where is tank located:
Limits:
$1 Million
$ 500,000
$300,000
