Questionnaire Selection Coverage List

Category: Service Businesses Risk: Dry Cleaning

GENERAL INFORMATION

Account: ____________________________________________________________________________

Account number: ______________________________________________________________________

Agency: _____________________________________________________________________________

Agency number: ______________________________________________________________________

Producer: ___________________________________________________________________________

Producer number: _____________________________________________________________________

Legal business name(s)

____________________________________________________________________________________

____________________________________________________________________________________

Mailing address :

____________________________________________________________________________________

____________________________________________________________________________________

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 and the filing date.

____________________________________________________________________________________

____________________________________________________________________________________

____________________________________________________________________________________

 

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 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 is the applicant open per week? ___

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:_________________________________________________________

Phone number of safety director: __________________________________________________

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: ____________________________________________________

Phone number of disaster coordinator:______________________________________________

Attach a copy of the disaster plan.