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| Primary Contact First Name
Last Name
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| Company:
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| Years Company has been in Business
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| Company Type:
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| Number of Owners:
Gross Sales
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| Tax ID or EIN
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| Number of Employees:
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Company Address:
City:
State:
Zip
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| Phone:(
Fax:(
Email:
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| List the states you do business in if more than one
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| Type of Business
& Description:
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| Please Describe Business in Detail:
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| Do you use sub contractors?
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| Coverage Information |
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Requested Aggregate Liabilty Limit:
Occurrence Limit:
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Company (not agency):
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| Any Losses in last 3 years?
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Please
describe any Losses give details and give dates
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General Questions for All Businesses |
| 1a.
IS THE APPLICANT A SUBSIDIARY OF ANOTHER ENTITY ?
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6. DURING THE LAST FIVE YEARS (TEN IN RI),
HAS ANY APPLICANT BEEN INDICTED FOR OR CONVICTED OF ANY DEGREE OF
THE CRIME OF FRAUD, BRIBERY, ARSON OR ANY OTHER ARSON-RELATED
CRIME IN CONNECTION WITH THIS OR ANY OTHER PROPERTY?
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| 1b.
DOES THE APPLICANT HAVE ANY SUBSIDIARIES?
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| 2.
IS A FORMAL SAFETY PROGRAM IN OPERATION?
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7.
ANY UNCORRECTED FIRE CODE VIOLATIONS?
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| 3.
ANY EXPOSURE TO FLAMMABLES, EXPLOSIVES, CHEMICALS?
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| 8.
ANY BANKRUPTCIES, TAX OR CREDIT LIENS AGAINST THE APPLICANT IN THE
PAST 5 YEARS?
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| 4.
ANY POLICY OR COVERAGE DECLINED, CANCELLED OR NON-RENEWED DURING
THE PRIOR 3 YEARS?
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9.
HAS BUSINESS BEEN PLACED IN A TRUST?
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| 5.
ANY PAST LOSSES OR CLAIMS RELATING TO SEXUAL ABUSE OR MOLESTATION
ALLEGATIONS, DISCRIMINATION OR NEGLIGENT HIRING?
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10. ANY FOREIGN OPERATIONS, FOREIGN PRODUCTS
DISTRIBUTED IN USA, OR US PRODUCTS SOLD/DISTRIBUTED IN FOREIGN
COUNTRIES?
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11. ANY MEDICAL FACILITIES PROVIDED OR MEDICAL
PROFESSIONALS EMPLOYED OR CONTRACTED?
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21. SPORTING OR SOCIAL EVENTS
SPONSORED?
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| 12. ANY EXPOSURE TO RADIOACTIVE/NUCLEAR
MATERIALS?
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22. ANY STRUCTURAL ALTERATIONS
CONTEMPLATED?
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| 13. DO/HAVE PAST, PRESENT OR
DISCONTINUED OPERATIONS INVOLVE(D) STORING, TREATING, DISCHARGING,
APPLYING, DISPOSING, OR TRANSPORTING OF HAZARDOUS MATERIAL? (e.g.
landfills, wastes, fuel tanks, etc)
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23. ANY DEMOLITION EXPOSURE
CONTEMPLATED?
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24. HAS APPLICANT BEEN ACTIVE IN OR IS CURRENTLY
ACTIVE IN JOINT VENTURES?
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14. ANY OPERATIONS SOLD, ACQUIRED, OR DISCONTINUED
IN LAST 5 YEARS?
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25. DO YOU LEASE EMPLOYEES TO OR FROM
OTHER EMPLOYERS?
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| 15. MACHINERY OR EQUIPMENT LOANED OR
RENTED TO OTHERS?
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26. IS THERE A LABOR INTERCHANGE WITH ANY OTHER
BUSINESS OR SUBSIDIARIES?
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| 16. ANY WATERCRAFT, DOCKS, FLOATS
OWNED, HIRED OR LEASED?
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27. ARE DAY CARE FACILITIES OPERATED
OR CONTROLLED?
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| 17. ANY PARKING FACILITIES
OWNED/RENTED?
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28. HAVE ANY CRIMES OCCURRED OR BEEN ATTEMPTED ON
YOUR PREMISES WITHIN THE LAST THREE YEARS?
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| 18. IS A FEE CHARGED FOR PARKING?
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29. IS THERE A FORMAL, WRITTEN SAFETY AND SECURITY
POLICY IN EFFECT?
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| 19. RECREATION FACILITIES PROVIDED?
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30. DOES THE BUSINESSES' PROMOTIONAL LITERATURE
MAKE ANY REPRESENTATIONS ABOUT THE SAFETY OR SECURITY OF THE
PREMISES?
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| 20. IS THERE A SWIMMING POOL ON THE
PREMISES?
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If you are a CONTRACTOR you must answer the following
questions: |
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1. DOES YOUR DRAW PLANS, DESIGNS, OR
SPECIFICATIONS FOR OTHERS?
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4. DO YOUR SUBCONTRACTORS CARRY COVERAGES OR
LIMITS LESS THAN YOURS?
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2. DO ANY OPERATIONS INCLUDE BLASTING OR UTILIZE
OR STORE EXPLOSIVE MATERIAL?
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5. ARE SUBCONTRACTORS ALLOWED TO WORK WITHOUT
PROVIDING YOU WITH A CERTIFICATE OF INSURANCE?
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3. DO ANY OPERATIONS INCLUDE EXCAVATION,
TUNNELING, UNDERGROUND WORK OR EARTH MOVING?
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6. DOES APPLICANT
LEASE EQUIPMENT TO OTHERS WITH OR WITHOUT OPERATORS?
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If you MANUFACTURE,
RESELL or REPACKAGE PRODUCTS |
you must answer the following
questions: |
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1. DO YOU INSTALL, SERVICE OR DEMONSTRATE
PRODUCTS?
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6. PRODUCTS RECALLED, DISCONTINUED, CHANGED?
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2. FOREIGN PRODUCTS SOLD, DISTRIBUTED, USED AS
COMPONENTS?
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7. PRODUCTS OF OTHERS SOLD OR RE-PACKAGED UNDER
YOUR LABEL?
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3. RESEARCH AND DEVELOPMENT CONDUCTED OR NEW
PRODUCTS PLANNED?
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8. PRODUCTS UNDER LABEL OF OTHERS?
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4. GUARANTEES, WARRANTIES, HOLD HARMLESS
AGREEMENTS?
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9. VENDORS COVERAGE REQUIRED?
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5. PRODUCTS RELATED TO AIRCRAFT/SPACE INDUSTRY?
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10. DOES ANY NAMED INSURED SELL TO OTHER NAMED
INSUREDS?
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Please
describe your product(s) in the box to the left:
1. How long each
one has been in the market place
2. Number of units
sold last year
3. Annual sales by
product line
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| Please list
any other information you feel is important or relevant to this
quote: |
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| How did you
find out about us?
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Please fill in the information in the graphic below then hit send me a quote.
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