Name*
Title*
Company*
Address1*
Address2*
City*
State*
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Deleware
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
District of Columbia
Guam
Puerto Rico
US Virgin Islands
Foreign County
Zip*
Business Website*
Business E-mail*
Business Phone *
( Please, no Cell Phones )
Extension
Best Time to Call
AM
PM
Industry Description
Total # of Affiliated
Companies*
Average # Employees
per Company*
Less than 10
10 - 19
20 - 49
50 - 99
100 - 249
250 - 499
Over 500
Average Annual Sales
per Company*
$0.0 - $0.5 Million
$0.5 - $1.0 Million
$1.o - $2.5 Million
$2.5 - $5.0 Million
$5.0 - $10.0 Million
$10 - $20 Million
$20 - $50 Million
$50 - $100 Million
$100 - $250 Million
$250 Million +
Average Total Assets
per Company*
$0.0 - 1.0 Million
$1.0 - $5.0 Million
$5.0 - $10.0 Million
$10.0 - $25.0 Million
$25.0 - $50.0 Million
$50.0 - $100.0 Million
$100.0 - $150.0 Million
$150.0 - $250.0 Million
$250.0 - $500.0 Million
$500 Million +
Average Pre Tax
Profit per Company*
Less than $350,000
#350,000 - $500,000
$500,000 - $1,000,000
$1,000,000 - $1,500,000
$1,500,000 - $2,000,000
$2,000,000 - $3,000,000
$3,000,000 - $5,000,000
Over $5,000,000
Total #
Employees All Companies*
Less than 10
10 - 19
20 - 49
50 - 99
100 - 249
250 - 499
Over 500
Total Annual Sales
All Companies*
$0.0 - $0.5 Million
$0.5 - $1.0 Million
$1.o - $2.5 Million
$2.5 - $5.0 Million
$5.0 - $10.0 Million
$10 - $20 Million
$20 - $50 Million
$50 - $100 Million
$100 - $250 Million
$250 Million +
Total Assets All
Companies*
$0.0 - 1.0 Million
$1.0 - $5.0 Million
$5.0 - $10.0 Million
$10.0 - $25.0 Million
$25.0 - $50.0 Million
$50.0 - $100.0 Million
$100.0 - $150.0 Million
$150.0 - $250.0 Million
$250.0 - $500.0 Million
$500 Million +
Total Pre Tax Profit
All Companies*
Less than $350,000
#350,000 - $500,000
$500,000 - $1,000,000
$1,000,000 - $1,500,000
$1,500,000 - $2,000,000
$2,000,000 - $3,000,000
$3,000,000 - $5,000,000
Over $5,000,000
Which of these Coverages do you
currently have? (Optional)
Business Owners
Yes
No
Professional Liability
Yes
No
Business Interruption
Yes
No
General Commercial
Yes
No
Commercial Auto
Yes
No
Employment Practices
Yes
No
Commercial Property
Yes
No
Directors & Officers
Yes
No
Commercial Umbrella
Yes
No
Crime and Fidelity
Yes
No
Do
you, or any members of your family, or any of your businesses
own any stock in a privately held insurance company?
Yes
No
