Name of applicant:

Address of applicant:

Location of risk:

Name of business:

Type of business:

Previous carriers and policies for last three years:

Losses past three years:

Policy effective date:

Insured value:

Property deductible:

Limit of liability:

Business classification:

Payment installment plan:

Name and address of mortgage/loss payee:

Name and address of lessor as additional insured:

Hired and non-owned auto coverage?

Year of construction:

Year of update if over 25 years:

Type of construction:

Number of floors:

Number of subterranean floors:

Total building area:

Area occupied by insured:

Percent of area sprinklered:

Other occupants of the building:

Position of occupant relative to insured location:

Number of full-time employees:

Number of part-time employees:

Number of fire extinguishers:

Type of alarm system:

Barred windows and/or doors?

Surge protection:

Dead-bolt locks:

Year insured started business:

Years of experience in business:

Years insured at this location:

Has insured ever filed for bankruptcy?

Sell or serve alcohol?

Annual gross sales:

Annual liquor sales (if any):

Percentage of sales from:

Any sale of used items:

Percentage of delivery:

Does store remain open after 10:00pm?

If yes, give store hours:

Is operation franchised?

Are foreign products directly imported and sold?

If yes, give details: