Company QuestionnaireGeneral Liability RequestProfessional Liability RequestCompany Questionnaire (D&O)GroupCompany Questionnaire Company QuestionnaireCompany NameAll Owners NameAddressContact PersonStreet AddressOwnershipSole PropertyPartnershipCorporationLLCOtherApt, Suite, Bldg. (optional) City State / Province / Region Business PhoneCell PhoneWebsite Address General InformationCompany QuestionariesInsurance CarierAny Claim in previous 4 yearsYesNoPolicy Expiration Date# of Full-Time Employees# of Part-Time EmployeesEmployee Payroll Amount (excluding owners):Years in BusinessYears of ExperienceVerificationPlease enter any two digits with no spaces (Example: 12)* Δ General Liability Request Company QuestionnaireCompany NameAll Owners NameAddressContact PersonStreet AddressOwnershipSole PropertyPartnershipCorporationLLCOtherApt, Suite, Bldg. (optional) City State / Province / Region Business PhoneCell PhoneWebsite Address General InformationLiability Limits $500,000 $1,000,000 $2,000,000 Business Personal Property (BPP) $30,000 $40,000 $50,000 other Description of OperationsCurrent Insurance CarrierAny claims in the past 5 years?YesNoPolicy Expiration DateAnnual Gross Receipts# of Full-Time Employees# of Part-Time EmployeesEmployee Payroll Amount (excluding owners):Years in BusinessYears of ExperienceHours of OperationProperty Information (only if requesting BPP):Location 1 tenant Owner Year BuiltConstruction Type Wood Frame Joisted Masonry Concrete Non-Combustible Building Type Free Standing Strip Mall or Plaza # of StoriesTotal Square FeetCustomer Area (Sq. Ft.)Sprinkler System Yes No Sprinkler System Yes No VerificationPlease enter any two digits with no spaces (Example: 12)* Δ Professional Liability Request Company QuestionnaireCompany NameAll Owners NameAddressContact PersonStreet AddressOwnershipSole PropertyPartnershipCorporationLLCOtherApt, Suite, Bldg. (optional) City State / Province / Region Business PhoneCell PhoneWebsite Address General InformationLiability Limits $500,000 $1,000,000 $2,000,000 Business Personal Property (BPP) $30,000 $40,000 $50,000 other Description of OperationsCurrent Insurance CarrierAny claims in the past 5 years?YesNoPolicy Expiration DateAnnual Gross Receipts# of Full-Time Employees# of Part-Time EmployeesEmployee Payroll Amount (excluding owners):Years in BusinessYears of ExperienceHours of OperationProperty Information (only if requesting BPP):Location 1 tenant Owner Year BuiltConstruction Type Wood Frame Joisted Masonry Concrete Non-Combustible Building Type Free Standing Strip Mall or Plaza # of StoriesTotal Square FeetCustomer Area (Sq. Ft.)Sprinkler System Yes No Sprinkler System Yes No VerificationPlease enter any two digits with no spaces (Example: 12)* Δ Company Questionnaire (D&O) Company QuestionnaireCompany NameAll Owners NameAddressContact PersonStreet AddressOwnershipSole PropertyPartnershipCorporationLLCOtherApt, Suite, Bldg. (optional) City State / Province / Region Business PhoneCell PhoneWebsite Address General InformationLiability Limits $500,000 $1,000,000 $2,000,000 Business Personal Property (BPP) $30,000 $40,000 $50,000 other Description of OperationsCurrent Insurance CarrierAny claims in the past 5 years?YesNoPolicy Expiration DateAnnual Gross Receipts# of Full-Time Employees# of Part-Time EmployeesEmployee Payroll Amount (excluding owners):Years in BusinessYears of ExperienceHours of OperationProperty Information (only if requesting BPP):Location 1 tenant Owner Year BuiltConstruction Type Wood Frame Joisted Masonry Concrete Non-Combustible Building Type Free Standing Strip Mall or Plaza # of StoriesTotal Square FeetCustomer Area (Sq. Ft.)Sprinkler System Yes No Sprinkler System Yes No VerificationPlease enter any two digits with no spaces (Example: 12)* Δ Group Company QuestionnaireCompany NameAll Owners NameAddressContact PersonStreet AddressOwnershipSole PropertyPartnershipCorporationLLCOtherApt, Suite, Bldg. (optional) City State / Province / Region Business PhoneCell PhoneWebsite Address General InformationLiability Limits $500,000 $1,000,000 $2,000,000 Business Personal Property (BPP) $30,000 $40,000 $50,000 other Description of OperationsCurrent Insurance CarrierAny claims in the past 5 years?YesNoPolicy Expiration DateAnnual Gross Receipts# of Full-Time Employees# of Part-Time EmployeesEmployee Payroll Amount (excluding owners):Years in BusinessYears of ExperienceHours of OperationProperty Information (only if requesting BPP):Location 1 tenant Owner Year BuiltConstruction Type Wood Frame Joisted Masonry Concrete Non-Combustible Building Type Free Standing Strip Mall or Plaza # of StoriesTotal Square FeetCustomer Area (Sq. Ft.)Sprinkler System Yes No Sprinkler System Yes No VerificationPlease enter any two digits with no spaces (Example: 12)* Δ