R.R.I.S. Business Owners Policy Questionnaire

        GENERAL INFORMATION:

        Please provide the following contact 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/Province
Zip/Postal Code
FEIN# or Social Security No.
Work Phone
FAX
E-mail
URL

        Please provide a detailed description of your operation:

        What year was your business established?

        Business Entity Type:

Sole Proprietor/Individual
Corporation
Partnership
LLC
Other

        How many full time employees?

        How many part time employees?

        Name of current/prior insurance carrier:

        What is/was the policy period?

        Any operations sold, acquired, or discontinued in the last five (5) years?

Yes
No

        If there have been any claims in the past five (5) years, please describe, including date of loss and amount paid.

        Do you have any subsidiaries or are you a part of another business?

Yes
No

        Are you open 24 hours per day?

Yes
No

        What were your gross sales the past 12 months?

        What will your gross sales be over next 12 months?

        Please choose general liability coverage options: (each occurrence/general aggreggate)

$300,000/$600,000
$500,000/$1,000,000
$1,000,000/$2,000,000
$1,000,000/$3,000,000
$2,000,000/$4,000,000

PROPERTY INFORMATION:

(Building information must be provided even if building coverage is NOT desired)

        Building Construction Type:

Wood Frame
Brick Veneer
Masonry Non-Combustible
Fire Resistive
Non-Combustible
Joisted Masonry

        Year Building Built:

        Number of stories?

        Square footage occupied by business

        Total square footage of building:

        Interest Type:

Owner Occupant
Tenant
Lessor's Risk
Home-Based

        If building is over 30 years old, indicate the year electrical was updated:

        Year of last roof repair/replacement:

        What type of plumbing (cast iron, PVC, copper, etc.) and when last updated:

        What type of heating and air (central, gas wall, electric, window air, etc.):

        Is there a fire hydrant within 1,000 feet of the building?

Yes
No

        Is the building within 1,000 feet of commercially navigatable body of water?

Yes
No

        Fire Alarm Type:

Centrally Monitored
Local
None

Burglar Arlarm Type:

Centrally Monitored
Local
None

        Does the building have a sprinkler system?

Yes
No

        If there is a loss payee/mortgagee/additional insured, please give name, address and loan number:

        What is the 100% Replacement Cost Value of your Business Personal Property? (includes business contents, inventory, computers, etc.)

        Business Personal Property Deductible:

$250
$500
$1,000
$2,500
$5,000
$10,000

        Do you wish to insure the building?

Yes
No

        Total Replacement Cost of Building:

        Building Deductible:

$250
$500
$1,000
$2,500
$5,000
$10,000

        Are there any restaurants, apartments or manufacturing exposures within the building? If so, please explain:

ADDITIONAL COVERAGE OPTIONS

        Do you need boiler coverage? If so, please provide contact name, phone and email address:

        Do you wish Hired Auto Physical Damage coverage?

Yes
No

If you wish a Commercial Automobile Quote, please complete our Auto Quote form (tab at top of this page).

If you wish a Workers' Compensation Quote, please complete our Workers Comp form (tab at tope of this page).