R.R.I.S. Manufacturing Operations Questionnaire                 

Please provide the following information:    

(The Referral Agent is the name of your Insurance Agent in our office or how you became aware of our website)

First Name
Last Name
Title
Organization
Street Address
Address (cont.)
City
State
Zip/Postal Code
Social Security #
Work Phone
Home Phone
FAX
E-mail
URL

Tell us about your business Business Name Business Type Choose One Sole Proprietor Partnership LLC Corporation Association Year Established Business Industry   Please briefly describe your business operation: Street City State Zip Code         Number of years at This Location   Do you own or lease this office space?   Choose One Own Lease Neither Number of locations in California   Number of Out-of-state locations   Current business owners insurance carrier (if applicable) Current Policy expiration (If applicable) Number of employees Number of company vehicles Approximate annual gross revenue Approximate annual payroll   Coverage Desired content Coverage Choose One $500,000 $1,000,000 $2,000,000 $3,000,000 $4,000,000 $5,000,000 Deductible for content Choose One $500 $1,000 $2,500 $5,000 $10,000 Liability coverage limit Choose One $500,000 $1,000,000 $2,000,000 $3,000,000 $4,000,000 $5,000,000   Comments Please list any additional coverage you need.    Ritchie & Rose Insurance Services, Inc. Bus  (530) 365-4705   Fax (866) 885-1428   DOI License No.  0F44143 sheriritchie@gmail.com Copyright © 2007 Ritchie & Rose Insurance Services, Inc. All rights reserved. Revised: 06/08/2013 04:35 PM