SIA - Business Owner Policy Form

City	State	Zip	County

Phone Number

Fax Number

Cell/Pager Number

Active E-mail Address

Preferred Method Of Contact

Mail:

Fax:

Phone:

E-mail:

Lic. # or App. Fee #	Classification	Entity (check one)
		Partnership	Sole Owner	Corporation

Business Type	Business Description	Prior Carrier

Years of Continual Coverage	Expiration Date

Was your company ever had a claim	Yes No
Was policy canceled or non renewed	Yes No

Please list as much about the claim as possible, including dates, names, and costs of injury.

Prior general aggregate liability limits or limit requested
Deductible request
General aggregate liability limits
What is your gross receipts per year

Yes or No Questions	Yes	No
Do you handle hazardous materials?
Do you make written guarantees or warrantees?
Have you ever claimed bankruptcy?
Do you have Sub-Contractors
If yes, do you make your Sub-contractor carry the same liability?
Do you require certificates of insurance from all Sub-Contractors?

How many buildings or locations are to be insured

Are you in a flood zone

Yes No

Value of the property to be insured
Value of contents to be insured

How many employees does your company have
What is your total annual payroll for labor

Are any of the buildings to be insured on piers, pilings, wharfs, or over water	Yes No
Do you want to cover your employee's payroll in the event of business interruption	Yes No
Do you want coverage for business income payroll in the event of business interruption	Yes No

If yes on previous question, what is your gross income monthy

For how long do you want the payments paid
Elimitation period

How did you hear about Skyles Insurance Agency?
	Construction Services	Economy Bonds	Mail Flyer
	Post Card	Friend	Already a Customer
	Web Search	Phonebook
	Other:

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