BUSINESS BACKGROUNDBusiness Name Contact Person Office Phone Cell Phone Fax Business Address E-mail Address EIN Description of Operation Mailing Address Prior Experience in Industry Years in Current Business LIABILITYPremises Liability Advertising and Personal Injury Liability Tenant Legal Liability Products and Completed Operations Non-owned and Hired Auto Employment Practices Liability Liquor Liability Professional Liability/Errors & Omissions Directors and Officers Umbrella Liability PROPERTYProperty Building Business Personal Property Computers and Media Stock and Inventory Transit/Off Premises Property of Others Valuable Papers Plate Glass Window Business Income/Extra expense Employee Dishonesty Accounts Receivable Money and Securities on premises/off premises Equipment Breakdown Flood Building Coverage Business Personal Property Computers and Media Stock and Inventory Transit/Off Premises Property of Others Valuable Papers Plate Glass Window Business Income/Extra expense Employee Dishonesty Accounts Receivable Money and Securities on premises/off premises Equipment Breakdown Flood EMPLOYEE BENEFITSEMPLOYEE BENEFITS Workers Compensation (Required by Law) Employee Benefits Liability Group Health Life Insurance/Group Life 401k Disability/Group Disability Key Man Life BUSINESS AUTOYear Make Model VIN Add Second Car Add One More Car Year Make Model VIN Add Third Car Add One More Car Year Make Model VIN Add Forth Car Add One More Car Year Make Model VIN Add Fifth Car Add One More Car Year Make Model VIN
