Manufacturing Insurance Quote - FarmerBrown.com - Illinois / Indiana / Chicago Insurance

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MANUFACTURING INSURANCE FORM

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Type of Business:	Sole Proprietor Corporation Partnership LLC
Contact Person:*
Phone Number:*	(xxx-xxx-xxxx)
Email Address:*
Address:

City:
State:
Zip:
Fax Number:	(xxx-xxx-xxxx)
Years in Business:
Building Square Feet:
Own or Lease Premises:
Number of Stories:
Basement:	yes no
Construction Type:	masonary masonary n/c frame
Year Built:	(yyyy)
Roof type composition:	shingle tile other
Roof Age:
Is there an automatic sprinkler system:	yes no
What type of product do you manufacture:
Claims in last three years:	yes no
If Yes, list claims details:
Number of Employees:
Total Payroll:
Bankruptcies or Tax Leins in past 5 years:	yes no
What types of alarms protect premises:
Do you imported materials used in your production from other countries:	yes no
Do you use materials that require special storage practices:	yes no
If Yes, explain your storage practices:
Are you participating in the research & development of any new product or are you planning any new products for sale in the next 12 months:	yes no
If Yes, please explain:
Do you service or repair products you did not manufacture:	yes no
Do you have a specific program to withdraw known or suspected defective products:	yes no
Have any of your poducts been subject to voluntary recall:	yes no
Policy Effective Date:
Policy Renewal Date:
Number of Vehicles to Insure:
Approximate Current Premium:
Current Insurance Carrier: