Category: Service Businesses Risk:
Abstracters
GENERAL INFORMATION
Account:
_____________________________________________________________________
Account number:
_______________________________________________________________
Agency:
______________________________________________________________________
Agency number:
________________________________________________________________
Producer:
_____________________________________________________________________
Producer number:
______________________________________________________________
Legal business name(s)
_____________________________________________________________________________
_____________________________________________________________________________
Mailing address:
_____________________________________________________________________________
_____________________________________________________________________________
Email:
________________________________________________________________________
Website:
______________________________________________________________________
Type of entity:
|
___ Individual
|
___ Corporation
|
___ Sub-S Corp.
|
|
___ Partnership
|
___ Joint Venture
|
|
|
___ Not-for-profit
|
___ Limited Liability
Company
|
|
SIC Code(s):
__________________________________________________________________
NAICS
Code(s):_____________________________________________________________________
Federal ID Number:
____________________________
When did the applicant
start business operations? ___________________________________________
When did the present
management assume control? _________________________________________
How many years experience
does the owner have in this type of business? _______________________
How many years experience
does the manager have in this type of business? _____________________
Has the applicant ever been
involved in a bankruptcy procedure? ___ Yes ___ No
If yes, explain including
the type of bankruptcy, the filing date, and the resolution.
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Names of subsidiary
companies or joint ventures that are not part of this application:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
|
Important People
|
Name
|
Phone Number
|
|
Owner/Principal
|
____________________________
|
______________
|
|
Other Decision Makers
|
____________________________
|
______________
|
|
Plant and Grounds
|
____________________________
|
______________
|
|
Financial
|
____________________________
|
______________
|
|
Legal
|
____________________________
|
______________
|
|
Claims
|
____________________________
|
______________
|
The applicant’s primary
operations are:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
The applicant’s secondary
and/or incidental operations are:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
The applicant used to be
involved in the following operations, but they have been discontinued:
_____________________________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
The hours of operations
are: _____________________________________________________________
How many days per week is
the applicant open? ___
Is this a seasonal
operation? ___ Yes ___ No
If yes, what is the season?
From: _____________ to: _____________
Does the applicant have a
safety program? ___ Yes ___ No
If yes, answer the
following:
Name
of safety director: _____________________________________________
Safety
director phone number: ________________________________________
Safety
director email address: ________________________________________
Attach
a copy of the safety program.
Does the applicant have a
disaster plan? ___ Yes ___ No
If yes, answer the
following:
Name
of disaster coordinator: ________________________________________
Disaster
coordinator phone number: ___________________________________
Disaster
coordinator email address: ___________________________________
Attach a copy of the disaster plan.
