Contact Name:*

Email:*

Phone:

Year business started:*

# of Active Owners and/or Partners:*

  --Pick-- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51+

# of Full Time Employees:*

  --Pick-- 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51+

# of Part Time Employees:*

  --Pick-- 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51+

# of Sub-Contractors:*

  --Pick-- 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51+

How many years of experience does the owner of your business have in your industry? *

  --Pick-- 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51+

Do you have any subsidiary businesses:

Yes No   If yes, how many:

What is your business legal entity?

Corporation S Corporation Limited Liability Company Limited Liability Partnership Partnership Sole Proprietorship Limited Partnership Professional Corporation Nonprofit Corporation

Year of Incorporation:*

What industry is your company in?

OFFICE Accountants/Bookkeepers Advertising Agencies Architects/Engineers Chiropractors' Offices Computer Consultants Consultants Doctors/Dentists/Medical Offices Dog Grooming Shops General Offices Graphic Designer Offices Inspection & Appraisal Services Interior Designers/Decorators Law Offices Management Consultants Manufacturers' Representatives Publishing Offices Real Estate Agents Travel Agents Veterinarians Other Office-based Industry SERVICES Appliance Installation Appliance Repair Day Care Dental Labs Dry Cleaners Funeral Directors Locksmiths Musical Instrument Repair Nursing Homes Office Machine Repair Photocopying & Blueprinting Photoengraving Photographic Studios Pool Maintenance Printing (Commercial) Printing (Instant Print & Duplic.) Radio & TV (Retail & Repair) Rehabilitative Services Shoe Repair Tailors Taxidermists Tour Services Tow Trucks Tree Services Trucking Other Service-based Industry MANUFACTURING Candy & Other Confec. Prod. Mfg. Canned Specialties Mfg. Computer Equipment Mfg. Electronics Mfg. Food Products Mfg. Household Audio & Video Equip. Mfg. Metal Mfg. Metal Working Job Shops Microbreweries Mfg. Office and Store Fixtures Partition and Shelves Mfg. Office Machines Mfg. Plastics Machines Mfg. Radio and TV Comm. Equip. Mfg. Tool and Die Patterns and Mold Mfg. Other Manufacturing-based Industry CONTRACTORS Janitorial Services Air Conditiong Contractors Cabinet Building & Installation Cable Installation Carpentry Carpet Laying Installation Ceramic Tile Installation Commercial Fence Contractor Drywall Installation Contractors Electrical Wiring Contractors Floor Covering Installation Frame Contractors General Contractor Glass/Glazing Work Contractor Heating Contractors Landscaping Masonry Contractor Painting/Wallpapering Plumbing Contractor Residential Contractor Roofers Telephone Equipment Installation Other Contracting-based Industry RETAIL/WHOLESALE Appliance Stores Automobile Dealerships Automobile Parts Bath Shops Bars Beauty Supplies Books/Magazines Retail Cameras & Supplies Candy/Nut & Confectionery Stores Carpet Retail Clocks Dance Clubs Drug Stores Electrical Supplies Florists/Garden Shops Gift/Souvenir Shops Greeting Cards Hardware Stores Health Food Stores Hearing Aids Hobby Shops & Model Stores Ice Cream Parlors Optical Goods Pet Shops & Pet Supplies Picture Frames Plumbing Supplies Restaurant Shoes Sporting Goods Tobacco Toys Trophies T-shirt Shops Video Tape Stores Other Retail/Wholesale Industry Other Airboat Related Alarms/Guards Apartments Churches & Synagogues Coastal Property Habitat Horse Related Import/Export Marine Non-Profit Organization Oil & Gas Parks Water Related

Detailed description of  the nature of business:*     

 Are you currently insured with D&O Insurance? 

  Yes No

If yes, what company? 

 Expiration Date:

Approximate current annual premium for D&O insurance(0 if not applicable):

Which of the following other coverages does your business already have? 
(check all that apply)

Commercial General Liability
Umbrella/Excess
Fiduciary Liability
Crime

Approximate amount of coverage needed:

$1,000,000
$2,000,000
$3,000,000
$4,000,000
$5,000,000+

Date Coverage Needed:*

Have you merged, acquired, purchased, sold closed, consolidated or spun off any company in the past 3 years or do you expect to in the next 12 months?

Yes No

Have you reorganized or made arrangement with creditors in the past 3 years or do you expect to in the next 12 months?

Yes No

Do you have any civil or criminal action or administrative proceeding pending?

Yes No

Are you currently the defendant in any lawsuit?

Yes No

Explanations to yes answers above and any other information your agent should know:

    *Indicates required information