Legal Name of Risk

Mailing Address

Phone#

Fax#

Describe your business

Number of Employees

Estimated Annual Payroll

Bldg Coverage

Yes No Limit

Contents Coverage

Yes No Limit

Any Commercial Auto

Yes No

Loss of Income

Yes No

Employee Dishonesty

Yes No

Building Ordinance

Yes No

Civil Authority

Yes No

Property off Premises

Yes No

Computers

Yes No

Spoilage

Yes No

Boiler & Machinery

Yes No

Liquor Liability

Yes No

Umbrella Coverage

Yes No

Employment Practices Liability

Yes No

Professional Liability

Yes No

Directors & Officers Liability

Yes No

Mold Coverage

Yes No

Terrorism Coverage

Yes No

Do you have any claims/losses in the past 5 years?

Yes No