Business Ins Supplement.htm

Selvaggio, Teske & Associates - Risk Management Partners for the Design and Build Industry

Business Insurance
Program Supplement

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*Indicates required fields

*Name of Insured:
*Contact Name:
*Street Address:
City: State: *Zip:
County:
*Phone:
Fax:
*Email:

General Information
Client is:	Individual Partnership Corporation
Number of years in business

Property Insurance Information:
Business Address (If different from above):
Street Address:
City: State: Zip:
County:
Phone:
Fax:
Email:

Has your business had any property or general liability losses within the past three years? If so, please indicate the amount below and briefly state the details.
Amount Paid:		Details:
Amount Paid:		Details:

Current Insurance Program:
Line of Business	Effective Date	Company	Premium
Property/Liability Package
Commercial Auto (if any)

General Information

Is the applicant a subsidiary of another entity or does the applicant have any subsidiaries?

Yes No

Is a formal safety program in operation?

Yes No

Any lawsuits within the last 5 years?

Yes No

Property

Building year of construction:

Building construction: Brick Frame Fire resistive

If combination, please provide details:

Year built:

No. of floors:

Total building square footage:

Square footage occupied by insured:

Other types of occupants:
(please describe)

Is there a basement?

Yes No

If building is over 30 years old, please provide years of modernization for the following:

Heating: Plumbing: Electrical: Roof:

Does the building have an indoor sprinkler system?

Yes No

Burglar Alarm: No Yes - Local Yes - Central Station:
Please provide Certificate #: for Central Station

Fire Alarm: No Yes - Local Yes - Central Station:
Please provide Certificate #: for Central Station

Liability

Does the insured own or have any interest in any other business/property in the same legal/business name not being rated for this policy?

Yes No

If yes, please explain:

Gross Receipts per Location

Location #1:

Location #2:

Location #3:

Payroll per Location

Location #1:

Location #2:

Location #3:

Total number of employees, except owners and partners, but including clerical staff:

Provide number of employees that are working away from the premises more than 10% of the time:

Location #1:

Location #2:

Location #3:

Has applicant been active or is currently active in a joint venture?

Yes No

If yes, please describe:

Is there a formal written safety and security policy in effect?

Yes No

Provide the following information for all Architects/Engineers:

Professional Liability Carrier:

Policy Number:

Policy Dates:

Policy Limits:

Crime

Is there an annual audit?

Yes No

Are checks countersigned?

Yes No

Are bank accounts reconciled by someone not authorized to deposit or withdraw funds?

Yes No

ERISA Plan name:

Plan Assets:

Automobile

Is the named insured or any person covered by this policy required to certify compliance with a financial responsibility law?

Yes No

Except encumbrances and long-term leases, are any vehicles not solely owned by and registered to the applicant?

Yes No

Do over 50% of employees use their personal autos in the business?

Yes No

Is there a vehicle maintenance program in operation?

Yes No

Are any vehicles leased to others?

Yes No

Are vehicles used by family members?

Yes No

If yes, please describe:

Are any vehicles customized, altered, or specially equipped?

Yes No

Any high performance vehicles?

Yes No

Are Motor Vehicle Report verifications obtained prior to hiring new employees?

Yes No

Any vehicles owned but not scheduled on current policy?

Yes No

Vehicle Schedule

Year	Make	Model	Serial No.	Garaging (City/State)

Driver Schedule

Name	Date of Birth	Driver's License #	Social Security #	State Licensed

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