Commercial General Liability And/Or Poperty

COMMERCIAL GENERAL LIABILITY AND/OR POPERTY

(BOP) APPLICATION

FirmName
ContactName
StreetAddress
City State Zip
Telephone Fax E-Mail
Underwriting Information
1. What is the nature of your business?

2. Is the business a Corporation, Partnership or Sole Proprietorship?
3. How many owners, partners and/or corporate officers are there?

Owners:Partners:Corporate Officers:
4. How many employees are there? Full-Time: Part-Time:
5. What is the total annual payroll amount?
Owners, Partners or Corporate Officers:
Full-Time (not including owners, partners or corporate officers):
Part-Time (not including owners, partners or corporate officers):

6. a) What is the total annual gross revenue or sales?
b) Indicate % earned at this location:
7. What is the FEIN?

8. Have you filed bankruptcy within the past three (3) years? Yes No
9. Year business established.
10. How many years of industry experience does the owner of the business have?
11. On average, how many hours per day does your business operate?
12. Do you have ownership interest in any other business? Yes No
13. Do you lease employees to or from other employers? Yes No
14. Have any of your business insurance policies been declined, non-renewed or cancelled in the last three (3) years? Yes No
Building & Property Information
15. a) What is the total square footage of the building you occupy?
b) LeaseOwn
c) Are there other occupants? Yes No
16. What is the total square footage of your business only?
17. How many stories is the building?
18. If it is two stories, what is the ground floor square footage?
19. What is the construction type? SelectBrickStoneFrameMasonrySuperiorLog CabinFrame-StuccoMasonry Veneer
20. What type of roof covering? SelectArchitectural shinglesAsphalt/Fiberglass shinglesBuilt-up/Tar and gravelClay tileConcrete tileCorrugated steelMineral fiber shakesMission TileRock roofRoll roofingRubber roofSlateTinWood fiber shinglesWood shake
21. a) What is the distance of the nearest fire hydrant? Ft.
b) What is the distance of the nearest fire department? Miles
22. How old is the building?
23. If the building is over 20 years old has the plumbing, electrical, roof and/or heating/AC been updated?

Yes No
If so, when?
24. Does the building have interior automatic fire sprinklers? Yes No
25. a) Is there are theft alarm? Yes No
b) % of building protected
26. a) Is there a fire alarm? Yes No
b) % of building protected
27. a) Is there a sprinkler system? Yes No
b) % of building protected
28. Are there any property or general liability losses or claims in the last 5 years? Yes No
29. If yes, what is the date, amount paid and description of each loss or claim?
Coverage Information
30. What is your current insurance company?
31. What is your expiration date?
32. Value of building, if owned?
33. Value of office contents?
34. Value of computer equipment & software?
35. How frequently do you deposit cash to the bank?
36. What is the maximum amount of money kept at your location overnight?

Are there any questions, comments or additional coverage required?

All information provided is confidential and will be used solely to obtain an indication for coverage. Coverage cannot be bound from this information sheet.

Please send to us in any of the following ways:

Email:

Fax: 972-235-3556

Mail: PO Box 515512

Dallas, TX75251