Herbert M. Sheaner, Jr. 
Insurance Agency

          General Information

*Business name
*Physical address
*City
State	Texas
*Zip code
*County
Entity	(choose one) Individual Partnership Corporation Non-Profit Organization LLP LLC Other (describe in remarks)
Interest of applicant	(choose one) Owner Owner/Occupant Tenant
*Contact name
*Email
*Phone
Fax
*Preferred means of contact	(choose one) Email Phone Fax Mail
*Description of operation	(choose one) Apartment Building Owner Artisan Contractor Automotive Repair Shop Information Technology Professional Office Restaurant Retail Manufacturing Photographer and photographer's studio Property owner/Landlord Wholesale Supply Other (please describe below)
*Please provide detailed description of operation
*Years in business	if less than 1 year, specify start up date                 in comments
If you answered less than 3 years, describe your prior experience

          Underwriting Information:

*Estimated annual gross sales/receipts	$
*Number of Owners, Partners, Officers, etc.
*Number of Employees
*Estimated annual employee payroll (excluding owner(s))	$
*Do you use Independent or Sub-Contractors?	(choose one) Yes No
If so, provide total cost of Independent Contractors	$
*What percentage of Independent and/or Sub-Contractors maintain their own insurance and provide you with Certificates of Insurance?	%
*If  working in construction trade; Do you perform or intend to perform any type of work on new single or new multiple family housing, new residential tract housing, new apartment, new townhouse, or new condominium projects?	(choose one) n/a Yes No
Current insurance company
Renewal date

        Loss Information

Please provide loss information for the last three years.

	*Have you sustained a covered or non-covered property loss the past three years  (choose one) Yes No   If Yes, please provide details below
Date of Loss	Loss 1Loss 2Loss 3
Amount paid	Loss 1Loss 2Loss 3
Describe loss

        Please provide any additional information or comments.