Camilleri & Clarke Associates

BUSINESS OWNERS POLICY QUESTIONNAIRE

(This form also available in PDF Version)

General Information
Firm Name:
Mailing Address:
County: Phone: Fax:
Legal Entity: Individual Partnership Corporation Other
Proposed Effective Date:
How many years have you been in business?
Hours of operation:

Value of Business Personal Property and Data Hardware and Software:	$
Specify any loss payments and types made in the past 3 years (if zero, please indicate zero)
Do you rent or lease to others any mechanical or construction equipment?	Yes No

Employment Information

Payroll Information

Executive:	$ Clerical / Inside Sales: $
Outside Sales:	$ Delivery / Drivers: $
Warehouse:	$
Total Organizational Revenue: $

Building Information

How many years have you been at your present location?
Insurable interest: Owner / Occupant Tenant Lessor's Risk
If you own the building, please provide:	Value of building: $
	Number of stories:
	% of building occupied:
Square footage of your office:
Total square footage of entire building:
Describe adjacent property (left, right, rear):
Construction: Frame Joisted Masonry Non-Combustible Fire Resistive Masonry Non-Combustible

Does your building have:
Sprinklers?	Yes No
Central air?	Yes No
Security system?	Yes No
Central station?	Yes No
Local alarms?	Yes No
Floor furnaces?	Yes No
Wall furnaces?	Yes No

Is there any X-Ray equipment located above the first floor?	Yes No

Type of Burglar Alarm: Local Central	Alarm Company:
Distance to Fire Hydrant:	feet
Distance to Fire Department:	miles
Distance from Ocean, Bay or Gulf:	feet (if less than 1 mile)

Building Occupancy

Please provide description of all tenant occupancies in the building and square footage occupied by each tenant:
Is there any habitation / residential occupancies in the building?	Yes No If YES, describe:
Is building a converted dwelling?	Yes No If YES, have front handrails been installed? Yes No
Is any portion of the building vacant or unoccupied?	Yes No If YES, % vacant or unoccupied:
Is there a restaurant in the building?	Yes No
Is there an ansul system installed?	Yes No N/A
Does the restaurant occupy less than 10,000 square feet AND less than 25% of the building?	Yes No N/A

Building History

Year building was built:
If building is over 25 years old, what year were the following update completed:
Roof: Electrical: Plumbing: Heating:

Electrical:
Have circuit breaks with 3 prong grounded outlets been installed?	Yes No
Have grounded fault circuit interrupters been installed?	Yes No
Does building have any working fireplaces / wood burning stoves?	Yes No
Is the property recognized as a landmark or historic property?	Yes No

Has the property ever been "gutted and refurbished"? Yes No
(definition - walls, ceilings, and floor have been stripped back to the studs & joists and have been rebuilt within the last 20 years. All electrical components (wiring, circuit breakers, outlets, switch boxes) have been brought up to code within the last 20 years. Plumbing and heating systems have been replaced / updated and roofing has been replaced / updated within the last 20 years.)

Coverage Information

During the past 3 years, has any coverage been canceled, declined, non-renewed or placed in residual markets?	Yes No If YES, explain:

Current BOP Carrier:
Liability Limit:	$
Deductible:	$
Expiration Date:
Premium:	$

Additional supplemental limits and coverages (Valuable Papers, Account Receivable, Money & Securities, Umbrella, Non-Owned & Hired Auto, Employee Benefits Liability, Employee Dishonesty, Fire Legal Liability, Fine Arts, etc.):
Direct Bill Payment Option: Annual 4 Pay 8 Pay 10 Pay
Mortgagee / Loss Payee Information:
Additional Insured Information: