Business Owner’s
Full Name: *
Business Name: *
Business Entity
Business Address: *
Address: *
City: *
State: *
Zip: *
Contact Number: *
Email: *
Website: *
Effective Start Date: *
Any losses in the last 5 years:
General Liability Limits:
(quotes baed on $1M in revenue)
Gross Revenue: *
Years in business: *
Years of Experience: *
Number of Employess Full-Time: *
Number of Employess Part-Time: *
Annual Payroll: *
Hired/Non-Owned Autos: Do employees use their personal autos to run business tasks:
Location Address (if different than mailing address): *
Number of Stories: *
Year built: *
Do you own the building:
Construction: *
Square footage you rent: *
Fire Sprinklers:
Year of updates if older than 25 years: Electrical:
Central station alarms
Dead Bolts on Exterior Doors:
Do you have a safe in the office:
Building Limit: *
Business Personal Property (*BPP) Limit: *
Note: Buliding Limit is n/a if you do not own the building / *BPP = the collateral amount for the SBA Load
Please separate the value of your electronic equipment -versus- the value of your Non-EDP equipment
Electronic Data Processing Equipment: (EDP) (value of equipment:
(includes Personal Computers, Monitors, Servers, Terminals, Laptops, Data Storage, Hardware, etc.) *
What is the value of your desk, chairs, file cabinets, and other misc. office furniture?: *