Legal Entity Name*

DBA*Type of Business*CorporationPartnershipSole ProprietorshipLLC

Contact Name*Phone*

Years in Business*Email*

Mailing Address(Street)*

City*State*ZIP*

Website*

Current Insurance Career*Current Premium($)*

Expiration Date*Effective Date*

Are you an association member?*YesNoAre you part of a Franchise?*YesNoDo you offer Tennant insurance?*YesNo

Loss History

Has your insurance ever been cancelled, denied, or non-renewed?*YesNoIf Yes, give reason:

List All Losses:

DescriptionDateAmount Paid($)DescriptionDateAmount Paid($)DescriptionDateAmount Paid($)

Facility Information

Facility Street Address*

City*State*ZIP*

General Liability Limit*Medical Payment Limit*

Customer Goods Legal Liability Limit*Sale And Disposal Liability Limit*

Employee Dishonesty Limit*Number of Employees*

Identity Fraud?*YesNoBuilding and Business Personal Property Limit:*Deductible:*

Construction(exterior walls/partitions/roof, incl. metal gauge)*

What type of access system do you use?*

Video surveillance/monitoring?*YesNoFacility fully fenced/enclosed?*YesNo

Individual door alarms?*YesNoFacility fully lighted at night?*YesNo

Automatic sprinkler entire property?*YesNoAny Vacant Land?*YesNo

Central alarm entire property?*YesNoIf Yes, system monitors:FireBurglar

Additional Insured/Loss Payee/ Mortgagee

Business Relationship*Additional InsuredLoss PayeeMortgageeOther

Name*

Address*

Email/Fax*

Submit