Questionnaire Selection Coverage List

IN HOME BUSINESS

Is the business located at the main residence operated on a full-time basis? ___ Yes ___ No

Are there any separate business locations? ___Yes ___No

Name under which business operates: _________________________________________

Please fully describe the business:

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

What is the form of ownership?

___Proprietorship ___ Partnership ____ Corporation (include type __________) ___ LLC

How many owners are involved in the business? ____

Number of employees (include family members): ____

If more than one owner or employee, are all persons members of the insured's household? ___Yes ___No

How long has the business been in operation? ____ Years ____ Months

What are the receipts? $____________products $_____________services

Total value of business personal property? $______________

Describe the business personal property:

___________________________________________________________________________________

Maximum value of others’ property on-premises: $_______________

Describe any property of others on-premises:

____________________________________________________________________________________

Total square feet of business operation? ____________________

If the business is RETAIL (other than crafts and food), answer the following:

Is the product distributed under your own private label? ___Yes ___No

The inventory is stored in the: ____House ____Attached garage ___Other structures

The customer receives the product by: ___ Mail/UPS ___ Customer pickup ___ Owner delivery

___Contract delivery ____ Other – Describe ________________________________________

Is the product sold by the applicant at fairs, flea markets, or similar events? ___Yes ___ No

If the business is SERVICE, answer the following:

Does the work involve: ___Installation ___ Consultation ___ Instruction

Does the applicant travel to jobsites ___ Yes ___ No

If yes, which vehicles are used? ____________________________________________

______________________________________________________________________

Does the applicant have a professional liability exposure? ___Yes ___No

If the business is CRAFTS, answer the following:

Is the product sold by the applicant at fairs, flea markets, or similar events? ___Yes ___ No

The customer receives the product by: ___ Mail/UPS ___ Customer pickup ___ Owner delivery

___Contract delivery ____ Other – Describe ________________________________________

If the business is FOOD RELATED, answer the following:

Is food prepared on premises? ___Yes ___ No

Is food prepared under a private label? ___ Yes ___No

Is food served off premises? ___Yes ___No

If the business is an OFFICE, answer the following:

Is the applicant a telecommuter for another business? ___Yes ___No

Does the applicant have a professional liability exposure? ___Yes ___No

Does the applicant have access to confidential information? ___ Yes ___ No

Do clients come to the residence to conduct business? ___ Yes ___No