BUSINESS OWNER WORKSHEET

First Name: Last Name: Business Name: Mailing Address: Mailing City: Mailing State: Select...AlaskaAlabamaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWisconsinWest VirginiaWyoming Mailing Zip Code: Phone Number: Fax Number: E-Mail Address: UNDERWRITING INFORMATION   Property Address:   Property City: Property State: California Property Zip Code: Property County: Please Describe the Nature of Your Business Number of Owners: Number of Employees: Payroll of Owners: Payroll of Employees: Total Annual Gross Receipts: Total Square Footage of the Building Your Business Is In: Square Footage Of Your Business Only: Current Insurance Company: Business License Number: License Type: Years of Experience: How Many Years Have You Operated This Business: How Many Stories: 1 2  If Two Stories, Ground Floor Square Footage:   Total Square Footage of Your Dwelling:   Construction Type: Frame Masonry Veneer Masonry Superior   Roof Type: Tile Slate Metal Woodshake Composite Material   Roof Updated: yes no  If Yes, Year Roof was Updated: Protection Distance: 1000 ft or less to a hydrant & 5 mi or less to a fire station Over 1000 ft to a hydrant & 5 mi or less to a fire station Over 5 & up to 10 mi to a fire station Over 10 mi to a fire station  Is The Business In A Brush Area? yes no  Is This Business Open 24 Hours A Day? yes no  Any Deep Frying (Food)? yes no  Is There Any Manufacturing, Mixing, Re-Labeling or Repackaging of Products? yes no  Is there Filing Of Propane Tanks? yes no  Is There Storage More Than 1500 Sq Ft? yes no  If An Office Risk, Is E With 1 Million Admitted Coverage Carried? yes no  Are There Smoke Detectors At This Location? yes no  Smoke Alarm: yesno Fire Extinguisher: yesno  Deadbolts On All Doors? yesno Circuit Breakers: yes no Electrical Updated: Yes, Updated No  Heating - Air Conditioning, Thermostatically Controlled?: yesno  Heating - Air Conditioning, Central? yes no  Plumbing Updated: yesno If Yes, Year Plumbing was Updated: Interior Automatic Fire Sprinklers:  None Partial Full  Theft Alarm: None Local Central  Fire Alarm: None Local  Losses-Claims in the last 5 years:  none one two three four five   If yes, date, amount paid and description of each loss-claim COVERAGE INFORMATION   Building Coverage:   Other Structures Coverage: Business Contents Coverage: Loss of Use Coverage: Liability Limits Requested: $100,000 $300,000 $500,000 $1,000,000  Policy Deductible: 100 250 500 750 1000 2500 5000  Questions or Comments to help the Agent: Please press the Submit Button ONCE. Then wait for online confirmation of your request. Thank you for your interest.