JM DOHERTY INSURANCE

1.

Insured Name:

Phone Number:

E-mail:

2.

Business Name:

Business Website:

3.

Address:

City:

State:

Zip:

5.

Tax ID Number:

6.

Effective Dates: to

7.

Desired/Renewal Premium: (Don’t Know )

8.

Current Insurer:

9.

Years in Business:

9.

Management Experience:

10.

Legal Entity (LLC? Corp? Partnership?):

11.

Nature of Business/Description of Operations:

12.

Total Gross Payroll:

13.

Total Sales:

14.

Liability Limits Desired:
300K 500K 1M

15.

Hours of Operation: From to

16.

Building Own or Lease? Own Lease
Values: $

17.

Building Questions:

Year Built:

Type of Construction:

Number of Stories:

Square Feet of the Business:

Burglar Alarm?: Yes No

Fire Alarm?: Yes No

18.

Is your loss ratio (average annual losses/quoted premium) Yes No
less than 40%?

19.

Employees:

Number of full-time employees?

Number of part-time employees?

Do you use temp workers? Yes No

Do you use sub-contractors? Yes No

20.

Any outstanding suits or liens against the business and/or any bankruptcies last 3 years? Yes No

How did you hear about us?

REQUIRED. By checking this box, I understand that the information above is to garner an indication only. Coverage can not be bound without additional information, including a signed application. All indications are pending favorable loss history for prior 3 years and favorable MVRs.

Business Owner's Package