Wholesaler Page

WHOLESALER INSURANCE FORM


Type of Business :	Sole Proprietor Corporation Partnership LLC
Contact Person :
Phone Number :	(xxx-xxx-xxxx)
EmailAddress :
Address :
City :
State :
Zip :
Number of Stories :
Roof type composition :
Roof Age :	years
Automated Sprinkler :	Yes No
Manufacturing Product :
Claims in last three years :	Yes No
Number of Employees :
Total Payroll :	$
Bankruptcies or Tax Leins in past 5 years :	Yes No
Materials Requiring Special Storage Practices :	Yes No
Any Retail Operations :	Yes No
Percent of Annual Sales Retail :
Percent of Annual Sales Wholesale :
Retail Operation Location :
Do Customers Purchase Products Via Internet :	Yes No
Percentage of Internet Sales:
Does Business Have Peak Season:	Yes No
Peak Season Month :
Percentage of Sales During Peak Season :
Specific Program to Withdraw Known or Suspected Defective Products :	Yes No
Have your Products been subject to Voluntary Recall :	Yes No
Policy Effetive Date :
Policy Renewal Date :
Approximate Current Premium :
Current Insurance :