General Information

Contact Name

E-Mail (required)

Business Name

Address

City

State

Louisiana

Zip Code

Parish

Business Phone (required)

Fax

Current Insurance Company (not agency)

Company Name

Current Expiration Date

Current Insurance Coverages

Bond

Commercial Auto

Commercial Liability

Commercial Property

Commercial Umbrella

Directors and Officers Liability

Disability

Group Health

Group Life

Professional Liability

Workers' Compensation

Other

# of Full-Time Employees

# of Part-Time Employees

How long in Business? (yrs)

How many locations?

Please give a brief description of your business and clientele.

Property/Premises Information

Address

Occupancy Status

Owner

Tenant

Year Built

% Occupied

Sprinklers

Yes

No

Construction Type

# Stories

# Basements

Square Footage

Burgular Alarm

Yes

No

Building Value

Contents

Other Property (specify)

Insurance Information

Other

Annual Gross Sales: (before taxes)

Number of Employees

Annualized Payroll

Cost of any Subcontracted Work

Limits Requested

$300,000

$500,000

$1,000,000

$2,000,000

Describe any claims you've had in the past 5 years

Additional Comments

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