(239) 657-3614
Immokalee, FL
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General Information
Contact Name
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Email
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Business Location Address
City
State
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Fax #
Business Information
Number of years in business
Number of Years in this profession
Annual Gross Sales (or projected if new in business)
Number of full-time employees
Number of part-time employees
Annual payroll
Number of locations
Brief description of your business & clientele
Seating capacity (if restaurant or pub)
Cost of any subcontracted work
Location/Premises Information
Address
Current Coverages
Bond
Commercial Auto
Commercial Liability
Commercial Property
Commercial Umbrella
Directors & Officers Liability
Disability
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Business Information
# 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
Frame
Brick Veneer
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Stories
# Basements
Sq. Footage
Burglar Alarm
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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
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