Questionnaire
Selection Coverage List
Category: Service Businesses Risk: Real Estate Agency
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.
LIABILITY – PROFESSIONAL
Provide a list of all licensed or certified individuals.
|
Name
|
License/Certification
|
Job
|
Responsibility
|
Years
Experience
|
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Are employees hired prior to state certification or license? ___ Yes ___
No
If yes, what is the process if the employee does not obtain the required
license or certification?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Have any employees been placed on probation by a licensing or
certification board? ___ Yes ___ No
If yes, explain what the employee did until the probation was lifted?
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Are non-professional employees permitted to perform any task for which
license or certificate is required?
___ Yes ___ No
If yes, which tasks and who is permitted to perform them.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
Describe continuing education and license update monitoring procedure
for all professionals.
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
