| YOUR COMPANY NAME: |
| HQ ADDRESS: |
| CITY: |
| STATE: |
| ZIP: |
| |
| WEBSITE: |
| |
| PHONE: |
| FAX: |
| |
| CONTACT NAME: |
| E-MAIL ADDRESS: |
| YEARS IN BUSINESS OR EXPERIENCE: |
| NUMBER OF EMPLOYEES: |
| NUMBER OF CORP. OFFICERS: |
| FEIN: |
| DESCRIPTION OF BUSINESS |
| |
| LIST MAJOR CLIENTS: |
| |
| OBTAINED CUSTOMER CONTRACT: Yes No |
| OBTAINED INSURED FINANCIAL STATEMENTS: Yes No |
| |
| GROSS REVENUES LAST YEAR: $ |
| GROSS REVENUES EXPECTED THIS YEAR: $ |
| NON U.S. REVENUES: $ |
| TOTAL PAYROLL LAST YEAR: $ |
| EXPECTED PAYROLL THIS YEAR: $ |
| |
| LOCATION 1: |
| ADDRESS: |
| |
| AGE OF BUILDING: |
| NUMBER OF STORIES: |
| SQUARE FOOTAGE OCCUPIED: |
| SPRINKLER SYSTEM Yes No |
| OTHER FIRE SUPPRESSION: |
| BURGLAR ALARM: Yes No |
| TYPE: |
| MONITORED BY: |
| CONSTRUCTION OF BUILDING: |
| TOTAL REPLACEMENT VALUE OF THE BUSINESS PROPERTY: $ |
| TOTAL REPLACEMENT VALUE OF THE COMPUTER EQUIPMENT: $ |
| DO YOU OWN THE BUILDING? |
| IF SO, WHAT IS THE BUILDING REPLACEMENT COST: $ |
| |
| LOCATION 2: |
| ADDRESS: |
| |
| AGE OF BUILDING: |
| NUMBER OF STORIES: |
| SQUARE FOOTAGE OCCUPIED: |
| SPRINKLER SYSTEM Yes No |
| OTHER FIRE SUPPRESSION: |
| BURGLAR ALARM: Yes No |
| TYPE: |
| MONITORED BY: |
| CONSTRUCTION OF BUILDING: |
| TOTAL REPLACEMENT VALUE OF THE BUSINESS PROPERTY: $ |
| TOTAL REPLACEMENT VALUE OF THE COMPUTER EQUIPMENT: $ |
| DO YOU OWN THE BUILDING? |
| IF SO, WHAT IS THE BUILDING REPLACEMENT COST: $ |
| |
LIST OF EMPLOYEES BY JOB DESCRIPTION AND SALARY
|
| (WORKERS COMPENSATION |
| JOB CLASS CODE SALARY (INCL 1099) |
If you need a list and explanation of WC classifications please email us at mrobertson@walkertaylor.com re: WC Classifications and we will email you a Word document. |
| |
| UMBRELLA POLICY LIMITS REQUESTED: |
| DO YOU NEED ANY OF THE FOLLOWING: ($1,000,000 - $5,000,000) |
| |
| PROFESSIONAL ERRORS AND OMISSION LIABILITY Yes No |
| MEDIA LIABILITY Yes No |
| DIRECTORS & OFFICERS LIABILITY Yes No |
| EMPLOYMENT PRACTICES LIABILITY Yes No |
| FIDUCIARY LIABILITY Yes No |
| CRIME (money, securities, employee dishonesty) Yes No |
| POLLUTION LIABILITY Yes No |
| AVIATION LIABILITY Yes No |
| INTERNATIONAL LIABILITY Yes No |
| KIDNAP RANSOM OR POLITICAL RISK Yes No |
| Email us if you need an explanation of any of the above at mrobertson@walkertaylor.com |
| |
HAS ANY INSURER CANCELLED OR NON-RENEWED
ANY INSURANCE COVERAGE? Yes No |
| |
| EXPIRING CARRIER: |
| EXPIRING PREMIUM: |
| ANY LOSSES IN THE LAST 3 YEARS? Yes No |
| IF YES, DESCRIPTION OF LOSS, INCLUDING DATE AND AMOUNT PAID: |
| DO YOU NEED RENTAL CAR PHYSICAL DAMAGE COVERAGE? Yes No |
| |
| OWNED AUTOS: |
| |
| YR: |
| MAKE: |
| MODEL: |
| VIN: |
| COST NEW: |
| USE: |
| GARAGING ADDRESS: |
| |
| YR: |
| MAKE: |
| MODEL: |
| VIN: |
| COST NEW: |
| USE: |
| GARAGING ADDRESS: |
| |
| YR: |
| MAKE: |
| MODEL: |
| VIN: |
| COST NEW: |
| USE: |
| GARAGING ADDRESS: |
| |
| |
