Inland Marine - Drag N' Drop FormBuilder

Inland Marine

Occupancy

Check box if you need to correct the address: *
- Incorrect

Corrected Address

How did you obtain the corrected address? *

Address: *
- Street address
- Street address 2
- - City
  - State / Province
- - zip code

Were you able to verify all the rating basis the customer requested? *
- Yes
- No

What rating basis were you unable to obtain? *

Was an interview conducted? *
- Yes
- No

Person interviewed (must be first and last name): *

Position and/or title: *

What was the other title? *

What date was the interview conducted? *
- Month
- Day
- Year

Was the agent contacted for assistance? *
- Yes
- No

You must contact the agent for assistance.

How many attempts were made to contact the insured and/or the agent? *

Type of Business

What type of business is on the property? *

Select all supplement forms that apply to this business: *
- None
- Restaurant/Cooking
- Convenience store
- Nightclub
- Laundromat/Dry cleaners
- Daycare
- Playground
- Swimming pool
- Nursing home/Assisted living

Occupancy Information

Select all supplement forms that apply to this type of business: *
- None
- Cooking
- Daycare
- Playground

Building Owner/Tenant

Is the insured the building/property owner or tenant? *
- Building owner only
- Building owner and occupies the building
- Tenant

Number of owners? *

Approximately what percentage does the building owner occupy? *

Does the owner have a tenant or tenants in the building? *
- Yes
- No

Does the owner require the tenant to provide proof of insurance naming the owner as an additional insured on their policy? *
- Yes
- No

What is the tenant square footage? *

Is the property vacant or partially vacant? *
- Yes
- No

What percentage of the building(s) is vacant? *

What are the insured's plans for the vacant property? *

Business Operations

Description of business operations: *

What type of business ownership? *

Insured's years of experience at this type of business? *

How long has insured been at this location? *

Does insured have other locations? *
- Yes
- No

How many other locations (including this location)? *

What type of neighborhood? *

Losses

Has there been any losses in the last 5 years? *
- Yes
- No

Describe in detail the loss (This must be more than just an answer of "Hail"): *

Date of last loss: *
- Month
- Day
- Year

Hours of Operation

How many days a week are they open? *

Average opening time? *

Average closing time? *

Contents

Does the owner have any contents in the building? *
- Yes
- No

Describe the building owner's contents: *

What is the content value? (In dollars): *

Does the tenant have any contents in the building? *
- Yes
- No

Describe the building tenant's contents: *

What is the tenant content value? (In dollars): *

Additional Notes

Additional Notes: *

Inland Marine

Type of operation *

Equipment Information

Did you attach a list of equipment with make, model, and s/n? *
- Yes
- No

Where is the equipment stored at night? *

What type of protection do they have? *

Describe the other type of protection: *

Are keys removed from all equipment when not in use? *
- Yes
- No

Where are the keys kept? *

Does the equipment have electronic GPS tracking devices? *
- Yes
- No

List all equipment that has a GPS tracker on it: *

How is the equipment transported to a jobsite? *

Is equipment leased to others? *
- Yes
- No

Does the insured supply the operator for the equipment leased? *
- Yes
- No

Do company name and ID# appear on the equipment? *
- Yes
- No

Are all serial numbers recorded and kept on file? *
- Yes
- No

Who maintains the equipment? *

Do they have a maintenance agreement? *
- Yes
- No

Are appropriate fire extinguishers in place? *
- Yes
- No

Are the fire extinguishers maintained annually by a professional firm? *
- Yes
- No

Cargo in Transit

What type of cargo/materials are being transported? *

Are there any hazardous or flammables being transported? *
- Yes
- No

How is the cargo being transported by? *
- Insured vehicles
- Private carrier
- Common carrier
- Other

Describe other type of transportation: *

Approximate distance to destination? (in miles): *

Approximate value of shipment? (in dollars): *

Are identifying data or serial numbers kept? *
- Yes
- No

Does cargo have permanent identification numbers? *
- Yes
- No