General Information

*Business name
*Physical address
*City
State	Texas
*Zip code
*County
Entity	(choose one) Individual Partnership Corporation Non-Profit Organization LLP LLC Other
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:

Number of Employees
*Estimated annual payroll	$
*Do you use Independent Contractors?	(choose one) Yes No
If so, provide total cost of Independent Contractors	$
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.