<p> BOP Questionnaire</p><p>APPLICANT INFORMATION:</p><p>Name:______</p><p>Mailing Address:______City:______</p><p>State:______Zip Code:______Business Phone:______Business Fax______</p><p>Email Address:______Website Address:______</p><p>( ) Corporation ( ) Joint Venture ( ) Not For Profit Org ( ) Subchapter “S” Corporation</p><p>( ) Individual ( ) LLC No. of members & Managers______( ) Partnership ( ) Trust</p><p>Proposed Effective Date:______</p><p>Prior Carrier Premium: General Liability $______Automobile $______Property $______</p><p>Description Of Primary Operations:______</p><p>SECTIONS ATTACHED:</p><p>Indicate Sections Attached Premium Premium Premium Accounts Receivable/ $ Electronic Data Processing $ Transportation/Motor $ Valuable Papers 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:</p><p>Limits:</p><p>General Aggregate $______Applies per: ( ) Policy ( ) Project ( ) Location ( ) Other</p><p>Products & Completed Operations Aggregate $______Personal & Advertising Injury $______</p><p>Each Occurrence $______Damage to Rented Premises (each occurrence) $______</p><p>Medical Expenses (Any one person) $______Employee Benefits $______</p><p>Schedule Of Hazards:</p><p>Classification Premium Base Exposure Ex.- Law Office, Retail Ex.- Square Footage, Sales Ex.- Square Footage Amount, Annual Sales</p><p>1 BOP Questionnaire</p><p>PROPERTY SECTION:</p><p>Premises Information:</p><p>Construction Type:______# of Stories______Yr. Built______Total Area (sq ft)______</p><p>Subject of Insurance Amount of Coverage Coins % Deductible Ex. Building, Contents</p><p>I am interested in additional coverage for the following:</p><p>( ) Commercial Auto</p><p>( ) Umbrella</p><p>( ) Accounts Receivable/Valuable Papers</p><p>( ) Electronic Data Processing</p><p>( ) Crime</p><p>Completed Form Can Be Mailed, Faxed or Emailed to:</p><p>OSBA Insurance Agency</p><p>1650 Lake Shore Dr., Ste. 100</p><p>Columbus, OH 43204</p><p>Phone: 614-572-0616</p><p>Fax: 614-572-0617</p><p> [email protected]</p><p>2</p>