TrustPoint Insurance - Business Owner

Who we represent:

BUSINESS OWNER INSURANCE QUOTE REQUEST

Personal Information
What is your name?	*Last
	*First
	*Middle
What is your business name?	Business Name
What is your address?	Street
	City
	State
	Zip
What is your telephone number?	Home
What is your telephone number?	Business
What is your fax number?	Fax
What is your email address?	*Email
Underwriting Information
What is the nature of your business?	Nature of Business
Is the business a corporation, partnership or sole proprietorship?	Corporation Partnership Sole Proprietorship
How many owners?	Number of Owners
How many employees?	Number of Employees
What is the payroll amount of the owners?	Payroll of Owners
What is the payroll amount of the employees?	Payroll of Employees
What is the total annual gross?	Total Annual Gross Receipts
What is the business license number?	Business License Number
What is the license type?	License Type
Years of experience in this business?	Years of Experience
How many years have you operated under your current business name?	Years Operated Under Current Name
Have you used any other business names during the past 5 years?	Other Business Names	Yes No
Is this business open 24 hours a day	Open 24 Hours	Yes No
Any deep frying (food)?	Deep Frying	Yes No
Is there any manufacturing, mixing, re-labeling or repackaging of products?	Manufacturing	Yes No
Is there filling of propane tanks?	Propane Tank Filling	Yes No
Please describe the nature of your business and ANY unusual exposures.	Unusual Exposures
Building & Property Information
What is the total square footage of the building your business is in?	Total Square Footage of Business Building
What is the total square footage of your business only?	Total Square Footage of Business Only
What is the square footage of the customer area only?	Square Footage of Customer Area
How many stories is it?	Stories
If it's two stories, what is the ground floor square footage?	Ground Floor Square Footage
What is the construction type?	Construction Type
What type roof covering?
If yes, what year?	Year Roof Updated
What is the distance of fire protection?
Is the business in a brush area?	Brush	Yes No
Do you have a storage area more than 1500 Sq. Ft.?	Storage Area	Yes No
Are there smoke detectors at this location?	Smoke Detectors	Yes No
Are there fire extinguishers?	Fire Extinguishers	Yes No
Are there deadbolts on all doors?	Deadbolts	Yes No
Are there circuit breakers?	Circuit Breakers	Yes No
Is the electrical updated?	Electrical Update
Is the heating/ air conditioning thermostatically controlled?	Thermostatically Controlled	Yes No
Is the heating/ air conditioning central?	Central	Yes No
Has the plumbing been updated?	Plumbing Updated	Yes No
If yes, what year was the plumbing updated?	Year Plumbing Update
Does the building have interior automatic fire sprinklers?	Automatic Fire Sprinklers	Yes No
Is there a theft alarm?	Theft Alarm	Yes No
Is there a fire alarm?	Fire Alarm	Yes No
Are there any restaurants in your building	Restaurants	Yes No
Are there any restaurants in the building next to your business?	Restaurants Next to Business	Yes No
Claims Information
Where there any losses or claims in the last 5 years?	Losses - Claims	Yes No
If yes, what is the date, amount paid and description of each loss or claim?
Coverage Information
What is the current insurance company?
How much are you paying now?	Amount Current Coverage
What is the liability limit requested?	Liability Limit
What is the building limit requested?	Building Limit
What is the building deductible requested?	Building Deductible
What is the business personal property (contents) limit requested?	Business Personal Property
What is the contents deductible requested?	Contents Deductible
What is the loss of income requested?	Loss of Income Coverage

Business Auto Garaging Information
What is the garaging address?	Street
	City
	State
	Zip

Driver Information
Driver 1	First Name
	Last Name
	Gender	Male Female
	Marital Status
	Years Licensed
	State Licensed
	License Type
Driver 2	First Name
	Last Name
	Gender	Male Female
	Marital Status
	Years Licensed
	State Licensed
	License Type
Driver 3	First Name
	Last Name
	Gender	Male Female
	Marital Status
	Years Licensed
	State Licensed
	License Type
Driver 4	First Name
	Last Name
	Gender	Male Female
	Marital Status
	Years Licensed
	State Licensed
	License Type

Vehicle Information
Vehicle 1	Year
	Make
	Model
	I.D. Number
	G.V.W.
	Miles per year
	Radius Driven (Average)
	Ownership
Vehicle 2	Year
	Make
	Model
	I.D. Number
	G.V.W.
	Miles per year
	Radius Driven (Average)
	Ownership
Vehicle 3	Year
	Make
	Model
	I.D. Number
	G.V.W.
	Miles per year
	Radius Driven (Average)
	Ownership
Vehicle 4	Year
	Make
	Model
	I.D. Number
	G.V.W.
	Miles per year
	Radius Driven (Average)
	Ownership

Violation Information

Last 3 years (minor violations)
Last 5 years (major violations)

Driver 1

Driver 2

Driver 3

Driver 4

Minor violations - speeding, turn, stop sign, red light, etc.

Accidents - non chargeable

Accidents - chargeable

Major violations - drunk driving, reckless, hit and run, etc.


Coverage Information
	Bodily Injury	Property Damage
Personal liability
Uninsured motorist
Medical payment


Deductible Information
	Vehicle 1	Vehicle 2	Vehicle 3	Vehicle 4
Comp (theft)
Collision


Miscellaneous Information
Current Insurance Company
Expiration date
Current premium

Are there any questions, comments or additional coverage required?	Questions, Comments or Additional Coverage

Please be advised that coverage cannot be bound, altered or amended by leaving a message at this web site. Please contact the local Trustpoint office that handles your account and our associates will be happy to assist you.