EUROPEAN-AMERICAN INC.

BUSINESS OWNERS Insurance Questionnaire
Please complete and return to EurAm
Company Name Street
Type of Applicant City
Telephone County
Telefax State / Zip
Website e-mail
    Federal Employer ID Number
Nature of Business
No. of Employees
Hours of Operation
Estimated Annual Sales $
 
Description of Operations &/or Products Manufactured or Distributed. Please provide brochures if possible!
 

PROPERTY
Location to be insured:
Street     Interest
City / State
Area Occupied     Square Feet %
Year Built Total Square Feet No. of Stories
Sprinklered Basement Present Is it finished
Construction Type Surrounding Exposures and Other Occupancies
 
Building Improvements
Wiring/Year Roofing/Year Heating/Year
Plumbing/Year Roof Material  
     
Limits of Insurance Required:
Building $ Deductible $
Personal Property $ Deductible $
     
 
 

LIABILITY
Limit Options:
Combined Single Limit each occurrence for Bodily Injury/Property Damage: $
Annual Aggregate $  
Fire Legal Liability $  
Medical Expenses per person $  
Deductible $  
Employee Benefits $  
Hired Auto & Non-Owned Auto $  
Liquor Liability $  

WORKERS COMPENSATION - please see separate questionnaire

ADDITIONAL COVERAGES
 
COVERAGE AMOUNT $ DEDUCTIBLE $
Extra Expense
Loss of Income
Valuable Papers
Accounts Receivable
Signs
Employee Dishonesty
Burg/Rob (Stock)
Burg/Rob (Money)
Money & Securities
Spoilage
Business Computers
Ordinance of Law
ERISA
Flood
Earthquake
Boiler & Machinery
Glass
General Information
1) Do/have past, present or discontinued operations involve(d) storing, treating, discharging, applying, disposing, or transporting of hazardous material (e.g. landfills, wastes, fuel tanks, etc.)?
2) Are athletic teams sponsored?
3) Are certificates of insurance required from subcontractors?
4) During the last ten years has any applicant been convicted of any degree of the crime of arson? (In Rhode Island failure to disclose the existence of an arson conviction is a misdemeanor punishable by a sentence of up to one year of imprisonment)
5)Describe any location/business interest owned/operated by applicant but not listed. Please include:
Annual Sales Receipts $ Total Annual Payroll $

SPECIALTY PROGRAMS

Apartments and Condominiums:      
1) Are there any swimming pools or playgrounds?    
2) Is aluminum wire used?    
3) Number of units per building or fire division?    
4) Indicate where coverage applies to:
Bare Walls Battery
Finished Walls Wired

5) Smoke Detectors:       None

     
Contractors:  
1) Does applicant draw plans, designs, or specifications?    
2) Do any operations include excavations, tunneling, underground work or earth moving?    
3) Does applicant lease equipment to others with or without operators?    
     
Restaurants:    
1) Is there an automatic fire protection system installed?    
2) Is there an automatic fuel cut-off?    
3) Is there a hood and duct service contract?    
Contract Expiration Date?    
Describe Off Premises Exposures:

CRIME

 
Alarm Type: Hold-Up
Premises
Safe/Vault
Alarm Description: Local gong Central Station w. Keys
  Central Station w/o keys Police Connect
Grade
Extent of Protection    
Safe / Vault Partial Complete
Premises Alarm: 1 2 3
Certificate No. Expiration Date
 
Safe/Vault Receptacle Manufacturer's Name:
Maximum Cash on Premises $
Maximum Cash with Messenger $
Money on Premises Overnight $
Frequency of Deposits $
Deadbolt Cylinder
Door Locks
Other Protection

ADDITIONAL INTEREST

Additional Insured Loss Payee
Mortgagee Lienholder
Employee as Lessor Certificate required
If applicable, please provide name and address, and brief details.
   
Prior Policies  
Insurance Company  
Policy Number  
Expiration Date  


Note: Completion of this application does not constitute a binder or obligate the applicant to purchase this insurance.

Desired Effective Date: Title:
Name: Date: