General Information:   1.  *First Name:   2.  *Last Name:   3.  *Phone:   4.  *Email:   5.  Address:   6.  Address:   7.  City:   8.  *State:   Select Your State Alabama Alaska Arizona Arkansas California Colorado Connecticut D.C. Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming 9.  *Zip Code:   9.  County:   The following questions concern the type of business insurance coverage you are requesting . Please answer them as accurately as possible. 1) Description of the business: Select One Agriculture, forestry and fisheries --Agricultural production- crops --Agricultural production- livestock --Agricultural services --Forestry --Fishing, hunting and trapping Mineral Industries --Metal mining --Coal mining --Oil and gas extraction --Nonmetallic minerals (except fuels) Construction Industries --General building contractors --Heavy construction contractors --Special trade contractors Manufacturing --Food and kindred products --Tobacco manufacturers --Textile mill products --Apparel and other textile products --Lumber and wood products --Furniture and fixtures --Paper and allied products --Printing and publishing --Chemicals and allied products --Petroleum and coal products --Rubber and miscellaneous plastics products --Leather and leather products --Stone, clay, glass and concrete products --Primary metal industries --Fabricated metal products --Industrial machinery and equipment --Electrical and electronic equipment --Transportation equipment --Instruments and related products --Miscellaneous manufacturing industries Transportation, Communication and Utilities --Railroad transportation --Local and inter-urban passenger transit --Motor freight transportation and warehousing --U.S. Postal Service --Water transportation --Transportation by air --Pipelines (except natural gas) --Transportation services --Communications --Electric, gas and sanitary services Wholesale Trade --Wholesale trade- durable goods --Wholesale trade- nondurable goods Retail Trade --Building materials, hardware, garden supply and mobile --General merchandise stores --Food stores --Automotive dealers and gasoline service stations --Apparel and accessory stores --Furniture, home furnishings and equipment stores --Restaurants, bars and dining facilities --Miscellaneous retail Finance, Insurance, and Real Estate --Depository institutions --Non-depository credit institutions --Security, commodity brokers and services --Insurance carriers --Insurance agents, brokers, and service --Real estate --Holding and other investment offices Service Industries --Hotels, rooming houses, camps, and other lodging --Personal services --Business services --Automotive repair, services, and parking --Miscellaneous repair services --Motion pictures --Amusement parks and recreational services --Health services --Legal services --Educational services --Social services --Museums, art galleries, botanical gardens and zoos --Membership organizations --Engineering and management services --Miscellaneous services Public Administration --Executive, legislative, and general government --Justice, public order, and safety --Finance, taxation, and monetary policy --Human resource administration --Environmental quality and housing --Economic program administration --National security and international affairs 2) Type of entity: Select One Individuals Corporation General Partnership Limited Partnership Limited Liability Company Other 3) Please indicate the state in which your business is located: Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri 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 U.S. Virgin Islands Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming 4) Date of incorporation/registration: MM/YY 5) Please indicate your total number of full-time employees: (If Sole Proprietor enter 1) 6) Please indicate your total number of part-time employees: (If none please enter 0) 7) Please indicate your total annual revenue: Select One Under $1,000,00 $1,000,000 -$10,000,000 $10,000,00-$25,000,000 $25,000,000-$50,000,000 over $50,000,00 8) Do you currently have business insurance: Yes No 9) If Insured, select current carrier: Select Carrier Company Not Listed Company Uknown 21st Century Casualty Insurance 21st Century Insurance A.G. Edwards AAA Insurance Co. AEGIS AETNA AIG Alliance For Affordable Service Allied Allstate Insurance Co. American Direct Business Ins. American Express American Family Insurance American General Insurance American Manufacturers Mutual American Mayflower Insurance American National Insurance Amica Mutual Insurance AXA Advisors Blue Cross And Blue Shield Cal Farm Insurance Charter Insurance Company Cigna Insurance Civil Service Employees Clarendon National Insurance CNA Colonial Insurance Co. Conseco Insurance Company Continental Insurance Copy Accounts Cotton States Insurance Country Insurance and Financial Services Dairyland Electric Insurance Erie Insurance Farm Bureau/Farm Family/Rural Farmers Insurance Group Farmers Union Insurance Fidelity Guaranty Fireman's Fund First General Insurance GEICO Insurance Co. General Accident GHS Property And Casulty Co. Golden Rule Insurance Grange Insurance Association Great American Insurance Guaranty Natl.(Orion) Hanover Insurance Co. Hartford Horace Mann Insurance Humana Insurance IDS Casualty IFA Auto Insurance Independent Agency - 31 Instant Auto Insurance Jefferson Pilot Insurance John Hancock Insurance Kemper Group Liberty Mutual Insurance Lumberman's Mutual Mass Mutual Mega Life And Health Ins. Metropolitan Insurance Co. Midwest Security Insurance Co. Millers Mutual Fire Misc. Mutual Of New York Mutual Of Omaha N.A.S.E. National General Nationwide Insurance Co. New Jersey Cure Insurance New York Life Insurance Northwestern Pacific Ohio Casualty Pennsylvania General Progressive Insurance Co. Progressive National Providian Prudential Insurance Co. Reliance Insurance SAFECO Sentry Insurance Co. Shelter Insurance Co. State Farm Insurance Co. Supplemental Accounts Titan-Victoria Insurance Top Term Rates Travelers/Primerica Insurance Tri-State Consumer Insurance UICI Unigard Unity Mutual Life Insurance USAA Viking 10) If not listed, please give company name: 11) How long, in years, have you had coverage with this company? 12) How long, in years, have you continuously had coverage without a lapse in coverage? 13) If you do not have coverage please indicate when you would like a policy to go into effect: Select One Immediately 15 Days 30 Days Other 14) Business address: 15) City: 16) State: Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri 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 U.S. Virgin Islands Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming 17) Zip Code: 18) Do you own or lease the location? Lease Own 19) Year built: 20) Number of stories in the building: 21) Which floor do you occupy: 22) Number of sq ft occupied 23) Construction type: Select One Wood Frame Brick / Masonry Veneer Steel Other 24) Does your suite have sprinklers: Yes No 25) Type of parking available: Select One Private Lot Public Lot Garage Street None Other 26) Are there day care facilities: Yes No 27) Outside cleaning services: Yes No 28) Is there a pool? Yes No 29) Is the pool fenced? Yes No 30) Does the building have security? Yes No 31) Type of security: Select One Central Local Guard Both None Other 32) Is your office located within 1000 ft of a fire hydrant? Yes No 33) Hours of operation Select One 12:00 AM 01:00 AM 02:00 AM 03:00 AM 04:00 AM 05:00 AM 06:00 AM 07:00 AM 08:00 AM 09:00 AM 10:00 AM 11:00 AM 12:00 PM 01:00 PM 02:00 PM 03:00 PM 04:00 PM 05:00 PM 06:00 PM 07:00 PM 08:00 PM 09:00 PM 10:00 PM 11:00 PM TO Select One 12:00 AM 01:00 AM 02:00 AM 03:00 AM 04:00 AM 05:00 AM 06:00 AM 07:00 AM 08:00 AM 09:00 AM 10:00 AM 11:00 AM 12:00 PM 01:00 PM 02:00 PM 03:00 PM 04:00 PM 05:00 PM 06:00 PM 07:00 PM 08:00 PM 09:00 PM 10:00 PM 11:00 PM 34) Do you work weekends? Yes No 35) Please list any scheduled personal property items or collectibles for which you need additional coverage. Please indicate the type and amount, for example, 'Computers $25,000.' Description:   Amount ($): Description:   Amount ($): Description:   Amount ($): Description:   Amount ($): Description:   Amount ($): Description:   Amount ($): Description:   Amount ($):   36) Liability Amount: Select One 100,000 300,000 500,000 1,000,000 2,000,000 Other 37) Deductible: Select One 250 500 1000 2500 5000 Other 38) Please check off any additional coverage's/riders you want your policy to include. Errors And Omissions Professional Liability Surety Bonds Fidelity Bonds Fire Insurance Miscellaneous Professional Liability   Umbrella Sexual Harassment Weather Insurance Workers' Compensation Directors and Officers Liability   Employee Dishonesty Product Liability Insurance Business Interruption Insurance Inland Marine Insurance General Liability   39) In the past five years have you reported any losses for the property? Yes No 40) If you have, were those claims: Select One Under 10000 25000-50000 75000-100000 Over 100000 Please complete the questionnaire, and we'll begin our search for the most suitable insurance policy for your business. 41) Best Time To Contact: Select One Anytime Morning at Home Morning at Work Afternoon at Home Afternoon at Work Evening at Home Evening at Work Weekends 42) Additional Comments: Please provide any additional information you feel is pertinent to the insurance coverage you need.

Copyright 2003 [Your Company Name.LTD]. All rights reserved