- Business Name:*
- Business Address:
- City:
- State:
- Zip:
- Contact Name:*
- Contact E-Mail Address:*
- Contact Telephone:*
- Paint Supplier, Dist., or Jobber:
HazWaste (hauler) disposal company:
Paint/Chemical Product Mfg. (primary):
- Number of wrk orders(repair orders) per month:
Total No employees: (incl owner/mgrs)
- Building square footage:
- Property square footage:
- Number of owned vehicles (trucks, cars, etc.):
*Required field; cannot be left blank
If Having Trouble, CALL: 1-888-374-7475
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- Average gross per work order:
- Employee payroll cost (per month):
-
- Est. gross income (per month):
- Avg. electric bill (per month):
- Avg. gas heat bill (per month):
- Avg. water bill (per month):
- Avg. HazWaste bill (per month):
- Insurance cost (per yr):
- Workers comp cost (per yr):
- Insurance renewal date (mo/yr):
- PROPERTY COVERAGE/LIMIT AMOUNTS:
- Building Value(Please note theft exclusion below):
- Content Value (Inc. Equip., Inventory & Property of Others):
- Electronic Data Processing and Equipment:
- Paint inventory & essential equipment:
- Loss of Business Income (Money needed post loss):
A professional specialist will contact you for
authorization to process your confidential application within 72 hours of receipt
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