Business Interruption Insurance

While property insurance may pay enough to replace damaged or destroyed equipment or buildings, how will you pay costs such as taxes, utilities and other continuing expenses during the period between when the damage occurs and when the property is replaced? Business Interruption (or "business income") insurance can provide sufficient funds to pay your fixed expenses during a period of time when your business is not operational.

Personal Information
1	First Name		Middle Initial

2	Last Name

3	Street Address		City

4	State		Zip Code

5	Email Address		County

6	Day Phone		Fax

7	Eve Phone

8	Social Security Number	*

9	Date of Birth:	*

10	Spouse Social Security Number:

11	Spouse Date of Birth:

12	Dwelling amount	.00

13	Property Coverage Deductible

14	Comprehensive Liability Amount

15	Medical Payments

16	Guaranteed Replacement Cost Coverage	Yes No

17	Water Backup Coverage	Yes No

18	Type Of Home

19	Year home built

20	Construction

21	Type of Roof

22	Year the roof was last upgraded:

23	Ground floor area (sq ft.)

24	Total basement area (sq ft.)

25	Number of Stories

26	Personal Property Amount (Applicable for condo owners or renters.)	$ .00

27	Distance to nearest fire hydrant

28	Distance to nearest fire station

29	Any Business conducted on premises?	Yes No

30	Inside or Outside of City?

31	Type of Alarm

32	Sprinklers?	Yes No

33	Animals?	Yes No

34	If yes, please provide breed

35	Number of Bathrooms

36	Attached Garage

37	3 Wall Addition? (square feet)

38	Percent of basement finished	%

39	Family Room	Yes No

40	Sun Room	Yes No

41	Den	Yes No

42	Separate Dining Room	Yes No

43	Any hardwood Floors	Yes No

44	Central Air Conditioning	Yes No

45	Decks (total square feet)

46	Porches (total square feet)

47	Large Laundry Room	Yes No

48	Large foyer	Yes No

49	Central Vac	Yes No

50	Video entry system	Yes No

51	Sauna	Yes No

52	Hot Tub	Yes No

53	Jacuzzi bath	Yes No

54	Dishwasher	Yes No

55	Trash Compactor	Yes No

56	Primary heating source:	*

57	Year the heating source was last upgraded:	*

58	Alternate heating source:	Yes No *

59	Foundation	*

60	Electric circuit breaker:	Yes No *

61	Deadbolt:	Yes No *

62	Fire extinguisher:	Yes No *

63	Smoke alarm:	Yes No *

64	Central alarm:	*

65	Swimming pool:	Yes No *

66	If yes, type:

67	Is homeowner's insurance currently in force?	Yes No *

68	If yes, with which company:

69	What is the expiration date:

70	Have you been declined, canceled, or not renewed in the last 3 years?	Yes No *

71	If yes, what was the reason:

72	Have you had any homeowner's claims in the last 3 years?	*

73	Is this a new purchase?

74	If yes, when is the closing date:

73	Is there any pre-existing damage to the risk?

74	If there is a woodstove, was it professionally installed?

75	Is the dwelling located within 400 feet of brush area, forested area or any area of increased fire hazard?

76	Is this dwelling vacant or is it located in a neighborhood with 3 or more vacant or condemned homes?

77	Is this dwelling in foreclosure?

78	Is this dwelling located in a commercial or industrial location?

79	Is the primary source of heat thermostatically controlled?

80	Does the dwelling have unusual or irreplaceable construction (including EFIS construction), cantilever construction, including dwelling on posts, stilts, and pilings (except where the result is required or authorized by current building codes to be elevated on posts/piers/pilings and there is no slope/stilts), or is a log or metal home, or utilizes asbestos siding/roofing?

81	Does the dwelling have copper or PVC Plumbing?

82	Are there any roommates or boarders in the home?

83	Do you show pride of ownership and properly maintain the premises of the dwelling?

84	Are any abandoned, non-operational, not regularly used, or commercial vehicles stored at this location?

85	Do you employ any domestic workers more than 10 hours per week at this dwelling premises?

86	Does the occupant of the dwelling have any horses, cows, sheep, chickens, or any other farm or exotic pets?

87	Has the applicant filed for bankruptcy in the last 10 years?

88	Is the dwelling owned/titled in the name of a church or non-profit organization or association?

89	Is this property located in a landslide or mudslide area?

90	Are there any trampolines at this location?

91	Is there a barn or other farming/ranching equipment on the premises?

92	Do you have legal title to the land on which the premises resides or a long term ground lease with more than 50 years remaining on the term of the lease?

93	Is this property located in a gated community?
COMMERCIAL PROPERTY QUESTIONS:
94	Business entity

95	Completely describe the operations at this location, including the number of buildings and the number of units per building.

96	How long has applicant been in this type of business?

97	How long has applicant been at this location?

98	Describe any commercial tenants, including related square footage

99	Number of commercial units currently vacant

100	Describe all adjoining or adjacent occupancies and/or vacancies

101	Total annual apartment rental receipts

102	Total annual commercial occupancy receipts

103	Number of apartment units (including manager’s unit)

104	Parking area sq ft or total number of parking spaces

105	Do units open to common interior hallways?	Yes No *

106	Does the building owner/manager live on the premises?	Yes No *

107	Describe all unusual operations or business practices not customary to this type of business.

108	Year policy history

109	Loss history for the last 4 years (include claims reported, unreported, and know occurrences which may result to claims) Description Date Amount Open/Closed

110	Has applicant had a fire loss at this or other property of business within 10 years?	Yes No *

111	If yes describe

112	Is the subject risk currently insured for both Property and Liability?	Yes No *