Manufacturing Insurance

MANUFACTURING INSURANCE FORM


Type of Business :	Sole Proprietor Corporation Partnership LLC
Contact Person :
Phone Number :	(xxx-xxx-xxxx)
EmailAddress :
Address :
City :
State :
Zip :
Fax Number :	(xxx-xxx-xxxx)
Years in Business :
Building Square Feet :
Own or Lease Premises :
Number of Stories :
Basement :	Yes No
Construction Type :	Masonary Masonary N/C Frame
Year Built :	(yyyy)
Roof type composition :
Roof Age :	years
Is there an automatic sprinkler system :	Yes No
What type of product do you manufacture :
Claims in last three years :	Yes No
If Yes, list claims details :
Number of Employees :
Total Payroll :	$
Bankruptcies or Tax Leins in past 5 years :	Yes No
What types of alarms protect premises:
Do you imported materials used in your production from other countries :	Yes No
Do you use materials that require special storage practices :	Yes No
If Yes, explain your storage practices :
Are you participating in the research & development of any new product or are you planning any new products for sale in the next 12 months :	Yes No
If Yes, please explain :
Do you service or repair products you did not manufacture:	Yes No
Do you have a specific program to withdraw known or suspected defective products :	Yes No
Have any of your poducts been subject to voluntary recall :	Yes No
Policy Effetive Date :
Policy Renewal Date :
Number of Vehicles to Insure :
Approximate Current Premium :
Current Insurance :