BUSINESS INSURANCE REQUEST FORM

Business Insurance Request Form
Pennsylvania

To receive a call from us, please fill out the form below.....

Company Name:
Contact Person:
Address:
City, St., Zip:
Phone Number:	Fax Number:
E-Mail:

Type:

Year Started:
If Business is new, what experience do you have in this type of business?

Annual Sales:$

Payroll:$

What does your business do.......

What type of coverage are you interested in....

Property: General Liability: Worker's Comp:

Cargo: Comml Automobile: Umbrella Liability:

Equipment: Liquor Liability: Health Insurance:

Life Insurance: Employee Benefits: Key Man Insurance:

General Information

Are you a subsidiary of another company or entity? Yes No

Do you have any subsidiaries? Yes No

Is a formal safety program in operation? Yes No

Any exposure to flammables, explosives or chemicals? Yes No

Any catastrophic exposures? Yes No

Any uncorrected fire code violations? Yes No

Any bankruptcies, tax or credit liens in the past 5 years? Yes No

Any policy or coverage declined, cancelled or non-renewed in the past 3 years? Yes No

Any past losses or claims relating to sexual abuse or molestation allegations, discrimination, or negligent hiring? Yes No

During the last 5 years, has any applicant been convicted of any degree of arson? Yes No

For any "YES" answers, please provide additional information...

Home Page

E-Mail

M c G R A T H   I N S U R A N C E   G R O U P

4170 William Penn Highway      Murrysville, PA. 15668-1890
(724) 327-8474          (FAX) 327-7911
Toll Free: 1-800-977-2999    (FAX) 1-888-800-0034

Property:	General Liability:	Worker's Comp:
Cargo:	Comml Automobile:	Umbrella Liability:
Equipment:	Liquor Liability:	Health Insurance:
Life Insurance:	Employee Benefits:	Key Man Insurance:

Are you a subsidiary of another company or entity?	Yes	No
Do you have any subsidiaries?	Yes	No
Is a formal safety program in operation?	Yes	No
Any exposure to flammables, explosives or chemicals?	Yes	No
Any catastrophic exposures?	Yes	No
Any uncorrected fire code violations?	Yes	No
Any bankruptcies, tax or credit liens in the past 5 years?	Yes	No
Any policy or coverage declined, cancelled or non-renewed in the past 3 years?	Yes	No
Any past losses or claims relating to sexual abuse or molestation allegations, discrimination, or negligent hiring?	Yes	No
During the last 5 years, has any applicant been convicted of any degree of arson?	Yes	No
For any "YES" answers, please provide additional information...