The Ted Hartleb Agency
Without the Love, it's just Insurance
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Business Insurance Questionnaire
Customer Name:
*
Phone/Fax:
*
Mailing Address:
*
Location Address:
*
Customer Type:
Corp
LLC
Sole Prop
FEIN/SS#
Line of Business:
Property
Liability
Work Comp
Inland Marine
Bond
Auto
Limit of Insurance:
100/200
300/600
500/1000
1000/2000
Umbrella Limit
Description of Operation:
Estimated Gross Sales:
Number of FT Employees:
Number of PT Employees:
Any Additional Insured’s:
Hired and Non-Owned Auto:
Liquor Liability:
Does applicant work on apartment buildings or tract housing?
Yes
No
Effective Date:
Previous Carrier:
Has applicant been convicted of arson, filed bankruptcy, been in a lawsuit or a judgment in the last 5 years?
Does the applicant have any subsidiaries or are they a subsidiary of another entity?
Yes
No
Year Business Started:
Number of year’s experience:
Website?
Yes
No
Does the applicant own another business or do they have other insurance?
Does the applicant perform maintenance on equipment?
Yes
No
Is there a formal safety program in existence?
Yes
No
1) Location:
Construction type:
Square feet:
Safety features- Alarmed/Sprinkler/Fire Supp:
Additional Occupancies:
2) Location:
Construction type:
Square feet:
Safety features- Alarmed/Sprinkler/Fire Supp:
Additional Occupancies:
3) Location:
Construction type:
Square feet:
Safety features- Alarmed/Sprinkler/Fire Supp:
Additional Occupancies:
1) Vehicle:
VIN:
GVW:
Special equipment:
Cost New:
2) Vehicle:
VIN:
GVW:
Special equipment:
Cost New:
3) Vehicle:
VIN:
GVW:
Special equipment:
Cost New:
1) Scheduled Equipment
Make:
Model:
Serial Number:
Cost New:
2) Scheduled Equipment
Make:
Model:
Serial Number:
Cost New:
3) Scheduled Equipment
Make:
Model:
Serial Number:
Cost New:
THIS IS NEITHER AN APPLICATION OR A CONTRACT, IT IS FOR INFORMATION PURPOSES ONLY.