Insurance Planning Services_17-0194-00

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FEIN #
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MonthDayYear
Years Experience/ Years in Business
Bankruptcy in last 6 years
Current Carrier
Expiration Date

MonthDayYear
Current Premium
Description of Operations
Provide List of any and all Claims/Loss Runs
PROPERTY
Owned/Leased?
# Buildings / locations
Construction Type
Year Built
Square Footage
Roof Type
Inside City Limits
Responding Fire Dept
Distance to Fire Hydrant
Mortgagee/ Additional Insureds
Sprinklered
Fire/Burglar Alarm
Smoke Detectors
Building Limit
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PAE
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GENERAL LIABILITY
Limits Requested
Gross Sales/ Receipt
Number of Officers
Number of Employees
Class Codes/ Payroll
Additional Insureds
COMMERCIAL AUTO
Limits Requested
Comp Ded
Collision Ded
Radius
Additional Insureds / Loss Payees
State Filing/ Type
Provide Vehicle List
Drivers List
INLAND MARINE
Total Limit
Leased / Rented Coverage Limit
Provide List of Equipment
WORKERS' COMPENSATION
3rd Party Limit
# of Employees
List of All Owners & % of Ownership:
Class Codes/Payroll
Experience Mod
Other/Notes: Garage Liab/Dealer Blkt/Keepers Umbrella Bonds Builders Risk Life Earthquake/Flood
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