First
And Last Name:
Address:
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
Zip:
County:
Home
Phone:
Work
Phone:
Cell
Phone:
Fax:
E-Mail:
Household
Income:
Select One
Less than $25k
$25-40k
$41-60k
$61-80k
$81-100k
$101-150k
$151-200k
$201-300k
over $300k
Own
Or Rent?
Own
Rent
Time
In Residence:
Select One
Less than 1 Year
1-5 Years
5-10 Years
10-20 Years
Over 20 Years
Social
Security Number:
Date
Of Birth:
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
Comments:
Company:
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
Type
Of Entity:
Select One
Individuals
Corporation
General Partnership
Limited Partnership
Limited Liability Company
Other
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
Date
Of Incorporation/Registration:
Please
Indicate Your Total Number Of Full-Time Employees:
Please
Indicate Your Total Number Of Part_Time Employees:
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
Do
You Currently Have Business Insurance:
Yes
No
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 National
Amica
Atlanta Casualty
Auto Owners
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
& Fin. Svcs
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
MSI
Mass Mutual
Mega 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
Pafco
Pemco
Preferred Risk
Primerica
Progressive
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
USF&G
Viking
Western National
If
Not Listed: Please Give Company Name:
How
Long In Years, Have You Had Coverage With This Company?
How
Long In Years Have You Contineously Had coverage Without A Lapse
In Coverage?
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
Liability
Amount:
Select One
100,000
300,000
500,000
1,000,000
2,000,000
Other
Deductible:
Select One
250
500
1000
2500
5000
Other
Additional
Coverage Riders :
In
The Past 5 Years Have You Reported Your Losses For The Property?
Yes
No
If
Yes: Were Those Claims:
Select One
Under 10000
25000-50000
75000-100000
Over 100000
Business
Address:
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
Zip
Do
You Own Or Lease The Location
Lease
Own
Year
Built
Number
Of Stories In The Building:
Which
Floor Do You Occupy?
Number
Of Sq Ft Occupied:
Construction
Type
Select One
Wood Frame
Brick / Masonry
Veneer
Steel
Other
Does
Your Suite Have Sprinkers
Yes
No
Type
Of Parking Available:
Select One
Private Lot
Public Lot
Garage
Street
None
Other
Are
There Day Care Facilities?
Yes
No
Outside
Cleaning Services:
Yes
No
Is
There A Pools?
Is
The Pool Fenced?
Does
The Building Have Security?
Type
Of Security
Is
Your Office Located Within 1000 Ft Of A Fire Hydrant?
Hours
Of Operation
Do
You Work Weekends
Please
Note Any Schedule Personal Property Items Or Collectibles For Which
You Need Extra Coverage