| COMMERCIAL ACCOUNT QUESTIONNAIRE Robert Bleistein NAMED INSURED_________________________________________ .DATE_____________________ __________________________________________________________ PRODUCER- BOB BLEISTEIN P.O. ADDRESS_____________________________________________ QUOTE X ISSUE_______ __________________________________________________________ EFFECTIVE DATE__________ CONTACT______________________________ PHONE NO.________________ Note: FAX______________________ EMAIL____________________ FEIN NO.__________________ WEB SITE_________________ BRIEF DESCRIPTION OF OPERATIONS (ATTACH PHOTOS &/OR BROCHURES) ---------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------- --------------------------------------------------------------------------------------------------------------------------------------------- __YEARS OF EXPERIENCE_____ COVERAGES: PROPERTY________ GL_______ W.C.¬¬¬________ CRIME_______ DBL_________ AUTO___________ PCKG.______ BOP______ UMBRELLA___ Liquor Liability ____OTHER___ PRESENT CARRIER(S) COVERAGE/POLICY NUMBERS EXPIRATION DATES ___________________ ____________________________ ___________________ ___________________ ____________________________ ___________________ ___________________ ____________________________ ___________________ GENERAL LIABILITY: AGGREGATE $_____________ OCCURRENCE$_____________ MED PAY$______ ANNUAL SALES OR RECEIPTS: $______________________________, PAYROLL:$______________ BUSINESS AUTOMOBILE: LIMITS: CSL $________________________, U/M____________________ ADD’L PIP LIMIT________________, OBEL: YES___ NO.____ BROADENED PIP- YES________, NO_______(NEED NAMES) DOC INCL.COMP & COLL: YES____, NO___(NEED NAMES) RENTAL REIMBURSEMENT: $______________DAILY LIMIT COMP. DED: ______________, COLL. DED: _______________ TOWING & LABOR: YES_____________, NO______________ OTHER: ______________________________________________ ATTACHMENTS: 1) SCHEDULE OF VEHICLES & COPIES OF REGISTRATIONS 2) COMPLETE LIST OF DRIVERS 3) USE OF VEHICLES (COMMERCIAL, SERVICE, RETAIL, BUSINESS OR PLEASURE) RISK LOCATION ADDRESS LOC. NO 1:____________________________________________________________________________ LOC. NO 2:____________________________________________________________________________ LOC. NO 3:____________________________________________________________________________ CONSTRUCTION: LOC: NO.1________________, NO.2________________ NO.3_________________ YEAR BUILT: LOC: NO.1________________, NO.2________________ NO3 __________________ NO. OF STORIES: LOC: NO.1 ________________, NO.2________________ NO.3 _________________ TOTAL Building AREA: LOC: NO.1________________, NO.2, ________________NO..3, _______________ AREAS OCCUPIED BY(you)INS’D: LOC: NO.1 ____________, NO.2 _____________, NO.3 ___________ FLOORS OCCUPIED BY INS’D: LOC: NO.1 ____________, NO.2 _____________, NO.3___________ OTHER OCCUPANCIES: ________________________________________________________________ ______________________________________________________________________________________ BURGLARY PROTECTION:_____________________________________________________________ FIRE PROTECTION: _____________________________________SPRINKLERED: YES____ NO_____ BLDG.(S) LIMIT: LOC: NO.1$________________, NO.2$________________,NO.3$________________ BPProperty LIMIT: LOC: NO.1$ ________________, NO.2 $________________, NO.3, $__________________ B/ Income. LIMIT: LOC: NO.1$_______________, NO.2 $_______________, NO.3 $_______________¬_ PROPERTY DEDUCTIBLE: $________________, PROPERTY CO.INS.______%, B.I. CO .INS._____% BLANKET COVERAGE: YES_____, NO_____ PLATE GLASS: DESCRIPTION & MEASUREMENTS - Linear Feet-_____________________________________ ______________________________________________________________________________________ CRIME: EMPLOYEE DISHONESTY $_____________, MONEY & SECURITIES INSIDE $_________ OUTSIDE $_________ (CRIME & FIDELITY SUPPLEMENTQUESTIONNNAIRES MAY BE REQUIRED) G.L. CLASSIFICATION PAYROLL SALES AREA LOC.1) ____________________ __________ __________ ________ LOC.2) ____________________ __________ __________ ________ LOC.3) ____________________ __________ __________ ________ WORKERS’ COMPENSATION CLASSIFICATION PAYROLL ALL STATES END’T: Y___ N___ _________________ $___________ OTHER: ______________________ _________________ $___________ _________________ $___________ NEW YORK STATE D.B.L: NUMBER OF MALES______ NUMBER OF FEMALES__________ BUILDING UPDATES BY YEAR: ELECTRICAL LOC. #1, __________#2, __________#3__________ PLUMBING LOC. #1, __________#2, __________#3__________ HEATING LOC. #1, __________#2, __________#3__________ ROOFING LOC. #1,__________ #2,__________ #3__________ LENGTH OF TIME W/AGENT ______, WHAT’S THE RELATIONSHIP W/AGENT________________ WHAT’S NEEDED TO WRITE THE BUSINESS? ____________________________________________ IS INSURED COMMITTED TO MOVE THE BUSINESS IF WE PERFORM? _____________________ HOW DID YOU GET TO THIS INSURED? _________________________________________________ HAVE ALL SUPPLEMENTAL APPLICATIONS BEEN COMPLETED? ______________________ ___ TAGS & CONTRACTS – Equipment_ |
 | |  | |  | |  | |  | |  |
 | |  | |  | |  | |  | |  | |  | |  | |  | |  | |  |