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Prior Coverage Carrier Policy Number Any Claims Effective Dates Expiring Dates Company Details Year building was built Area square footage Percentage occupied Location inside/outside city limit Location owned/rented Any prior coverage declined, none renewed or cancelled? Any foreign operations? Any Contractors? If yes, do you draw plans, designs or specifications for others? Do operations include blasting or utilize explosive material? Any operation excavation, tunneling, underground work or moving earth? Do subcontractors carry coverage or limits less than yours? Any subcontractors allow to work without certificate of insurance? Do you lease equipment to others with or without operators? Dollar amount paid to subcontractors: Percentage of work subcontracted: Number of full time employees: Number of part time employees: Any products/ completed operations included? If yes, product name/annual gross sales/number of units/time in the marketed/intended use/principle component Do you install service or demonstrate products? Are there any foreign products sold, distributed, used as components? Any new products planned? Guarantees, warranties, hold harmless agreements? Any products related to aircraft or space industry? Products of others sold or repackaged under your label? Products under label of others? Vendor's coverage required? Does any named insured sell to any other named insured? Any additionally insured/loss payee/mortgagee/lien holder/employee as lesser? Any medical facility provided or medical professional employee contracted? Any exposure to radioactive or nuclear material? Any transporting of hazardous material? Any operations sold, acquired or discontinued in the past 5 years? Any machinery or equipment loaned or rented to others? Are you active or had been in joint ventures? Do you lease employees to or from others? Is there a lab or interchange with any other business or subsidiaries? Has any crime occurred on premises in the past 3 years? Property Details Year heat was updated: Distance from fire hydrant (feet), distance from fire station (miles) Subject of insurance / amount /deductible: Any loss payee or mortgagee? If yes, please provide name and address. Percentage sprinklers:
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