Applicant Information s9

BOP Questionnaire

APPLICANT INFORMATION:

Name:______

Mailing Address:______City:______

State:______Zip Code:______Business Phone:______Business Fax______

Email Address:______Website Address:______

( ) Corporation ( ) Joint Venture ( ) Not For Profit Org ( ) Subchapter “S” Corporation

( ) Individual ( ) LLC No. of members & Managers______( ) Partnership ( ) Trust

Proposed Effective Date:______

Prior Carrier Premium: General Liability $______Automobile $______Property $______

Description Of Primary Operations:______

SECTIONS ATTACHED:

Indicate Sections Attached / Premium / Premium / Premium
Accounts Receivable/
Valuable Papers / $ / Electronic Data Processing / $ / Transportation/Motor Truck Cargo / $
Boiler & Machinery / $ / Equipment Floater / $ / Trucker/Motor Carrier / $
Business Auto / $ / Garage and Dealers / $ / Umbrella / $
Business Owners / $ / Glass and Sign / $ / Yacht / $
Commercial General Liab. / $ / Installation/Builders Risk / $
Crime / $ / Open Cargo / $
Dealers / $ / Property / $

COMMERCIAL GENERAL LIABILITY SECTION:

Limits:

General Aggregate $______Applies per: ( ) Policy ( ) Project ( ) Location ( ) Other

Products & Completed Operations Aggregate $______Personal & Advertising Injury $______

Each Occurrence $______Damage to Rented Premises (each occurrence) $______

Medical Expenses (Any one person) $______Employee Benefits $______

Schedule Of Hazards:

Classification
Ex.- Law Office, Retail / Premium Base
Ex.- Square Footage, Sales / Exposure
Ex.- Square Footage Amount, Annual Sales

BOP Questionnaire

PROPERTY SECTION:

Premises Information:

Construction Type:______# of Stories______Yr. Built______Total Area (sq ft)______

Subject of Insurance
Ex. Building, Contents / Amount of Coverage / Coins % / Deductible

I am interested in additional coverage for the following:

( ) Commercial Auto

( ) Umbrella

( ) Accounts Receivable/Valuable Papers

( ) Electronic Data Processing

( ) Crime

Completed Form Can Be Mailed, Faxed or Emailed to:

OSBA Insurance Agency

1650 Lake Shore Dr., Ste. 100

Columbus, OH 43204

Phone: 614-572-0616

Fax: 614-572-0617