Commercial Questioner

Applicant Name:

Date of Birth:

Business Name:

Business Address:

Business Phone Number:

Business Fax Number:

Business Entity: Individual Partnership Corporation

Business Tax ID or Applicant Social Security:

How Long in This Business:

How Long in This Location:

Left Exposure:

Right Exposure:

Back Exposure:

Parking: Common Private Valet

Parking Size:

Number of Full Time Employee:

Landlord Name, Phone, and Address If you want your landlord as additional Insured

Number of Part Time Employee:

Annual Payroll:

Total Area of your location:

Building Age (Year Built):

How many stores:

Type of Construction: Frame Concrete Block Masonry

Building Fire Protection: Fully Sprinkler Partial Sprinkler None

Plumbing: Copper Galvanize

Plumbing Last Update:

Electrical: Circuit Breaker Fuzzes

Electrical Last Update:

Heating: Natural Gas Electric

Heating Last Update:

Type of Roof: Tile Composition Metal

Roof Last Update:

Business Hours:

How Many Davs a Week:

Annual Gross Sale (excluding liquor):

Annual Liquor Sale:

Annual Entrée Price:

Liquor Receipt are % of total receipt.

Is there entertainment, bouncers or dancing?

Yes, please explain

Does the insured operate micro brewery at any location?

Yes No

Total Equipment Value:

Total Inventory Value:

Lease Hold Improvement:

Out side Sign Value:

Alarm Yes No

Alarm Company

Alarm License Number:

Prior Insurance Carrier:

Policy Number:

Renewal Date:

Losses in Last 5 Years:

	Date of Loss	Type of Loss	Amount of Loss	Close/Open
1)
2)
3)

Please describe your business:

Garage Keepers:

How Many Cars Kept Over Night:

Inside:

Outside Fence:

Average Value of Repairing Auto:

Highest Value of Repairing Auto:

Do you repair exotic Auto or Racing Car (please Explain): Yes No

Name and Drivers License number of all employees:

	Name	Driver License
1)
2)
3)
4)
5)

Total Equipment Value:

Total Inventory Value:

Tenant Improvement Value:

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