Walterry Insurance: Commercial Business Insurance Products Application GENERAL INFORMATION Contact Name Entity Type Street Address City/State/Zip Home Phone Business Phone Fax# Contact Years in Business Effective Date Email: Description of Operations Annual Gross Sales $ Premises Information Left Right Street, City, County, State, Zip Yr Built Sq Footage Construction Alarm Exposure Exposure 1 select one Frame Masonry Non-Combustible Yes No Yes No Yes No 2 select one Frame Masonry Non-Combustible Yes No Yes No Yes No 3 select one Frame Masonry Non-Combustible Yes No Yes No Yes No Any Claims in the past 36 months? Yes No CLAIMS DATE DESCRIBE TYPE OF LOSS COMPANY PAID PROPERTY SECTION AMOUNT OF DESCRIPTION COVERAGE Building Contents Business Interruption Extra Expense OPTIONAL COVERAGES Accounts Receivable Valuable Papers Outdoor Sign Building Glass Property Off Premises Personal Effects Property of Others Money/Securities -Inside Money/Securities -Outside Employee Dishonesty Computer Hardware Computer Data/Media Systems Breakdown ANNUAL DEDUCTIBLE select one $100 $250 $500 $1,000 UNDERWRITING #1 If over 20 years, Old Dates Updated Roof Electrical Plumbing Heating #2 If over 20 years, Old Dates Updated Roof Electrical Plumbing Heating GENERAL LIABILITY OCCURRENCE AGGREGATE FIRE/LEGAL MEDICAL choose one $300,000 $500,000 $1,000,000 $2,000,000 choose one $300,000 $500,000 $1,000,000 $2,000,000 choose one $50,000 $100,000 $250,000 $500,000 $1,000,000 choose one $1,000 $2,500 $5,000 $10,000 Classification: (Describe your business here) State Payroll $ Sales $ Payroll $ Sales $ Payroll $ Sales $ WORKERS COMPENSATION Classification: (Describe your business here) State Payroll $ Payroll $ Payroll $ Officers/Partners select one Included Excluded Federal ID # Experience Modification Factor: Number of Employees: AUTO SECTION LIABILITY UNINSURED MOTORIST MEDICAL COMPREHENSIVE COLLISION PIP choose one $100,000 $300,000 $500,000 $1,000,000 choose one $100,000 $300,000 $500,000 $1,000,000 choose one $1,000 $2,500 $5,000 choose one $100 $250 $500 $1,000 choose one $100 $250 $500 $1,000 choose one BASIC $5,000 AUTO SCHEDULE Garaging Describe Cost Year Make/Model Vehicle ID# Zip Use Comp. Collision New 1 Yes No Yes No 2 Yes No Yes No 3 Yes No Yes No 4 Yes No Yes No 5 Yes No Yes No Driver Information Name License # D.O.B. 1 2 3 4 5 Copyright © 2005 Walterry Insurance Brokers [ Forms ] [ Contact Us ] [ Privacy Policy ] [ Home ]