Personal Home, Auto, and Other Insurance
Home Based Business Insurance
Commercial Insurance
Life, Health, and Disability Insurance
 
THIS FORM IS FOR

Home Business
Small Business

HOME BASED BUSINESS


If you are a homeowner who operates a business out of your home, this program is designed for you. Our Home Based Enterprise Program combines both homeowners and business coverages in a single policy, giving you the necessary protection and convenience at a competitive price.

(*not available for rental homes, must be owner occupied)

CONTACT INFORMATION
  Salutation
* First Name
* Last Name
* Mailing Address
* City
* State
* Zip/Postal Code
* Email Address
* Daytime Phone Include area code
  Mobile / Cell Phone Include area code
  Business Fax Include area code
  Receive Free Quote By

CURRENT HOMEOWNERS INSURANCE COMPANY
  Company Name
  Policy Expiration Date
  Amount Inured For
  Premium
  Deductible

HOME INFORMATION
  How long at present address yrs     months
  Square footage (excluding garage/basement) sq ft
  Year home was built
  # Claims in last 3 yrs
  List Dates & Description of losses

STRUCTURE INFORMATION
Type Construction Foundation
Roof Type Garage Size # Full Bath
Age of Roof yrs Garage Type # Half Bath
Deck SqFt # Chimneys Basement Type
Porch SqFt # Hearths Basement SqFt
Screen Patio SqFt Fireplace Insert / Woodburning Stove Yes   No
Heating System Central Air Yes   No Central Vac Yes   No
Security System Fire Alarm System # Smoke Detectors
Electrical Breakers
Fuses		 Distance to Hydrant feet Miles to Fire Station mi
Pool Yes   No Diving Board Yes   No Slide Yes   No

OTHER INFORMATION
Trampoline Yes   No Bars on Windows or Doors Yes   No
Filed for Bankruptcy Yes   No Ever Convicted of a Felony Yes   No
Pets-Number and Breed (exact name of breed must be provided)
Any Business Conducted
from Home		 Yes   No Any Day Care Provided
at Home		 Yes   No
Scheduled Personal Property
Total Limit $15,000
Jewelry Stamps Coins Silver
Fine Arts Cameras Furs Computers
Golf Equipment

GENERAL INFORMATION REGARDING HOME BUSINESS
Full, Legal Name of the Business
Type of Business Corporation   Sole Proprietorship
Partnership   LLC
Other  
Describe the business operated from the applicant's home
How long has the applicant been in business yrs     months
Has the applicant had any previous business ventures Yes   No
If yes, describe these ventures
Are there any other business activities not described in this questionnaire Yes   No
If yes, describe in detail
Does applicant carry Professional Liability or Errors or Omissions Liability coverage Yes   No
If yes, state the limits, carrier, and expiration date
Does applicant store, service, repair or perform any processing at the residence premises on products belonging to others Yes   No
If yes, describe in detail
Is there any processing, packaging, or assembly done in conjunction with the products of this business Yes   No
If yes, describe in detail
Number of full-time and part-time employees, including applicant and any family members active in the business Full-Time     Part-Time
Describe the duties of all employees
What are the estimated annual receipts for this business
What are the annual receipts for the prior three years  
 
 
Are there any autos used in this business Yes   No
If yes, describe each
Do any employees use their own vehicles in the business Yes   No
If yes, describe in detail
COMMENTS - include any additional information which may assist the underwriter in evaluating the application.