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
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 Drivers	(choose one) 1 2 3 4 5
*Driver One	age Married Single Male Female
Driver Two	age Married Single Male Female
Driver Three	age Married Single Male Female
Driver Four	age Married Single Male Female
*Do all drivers have clear driving records?	(choose one) Yes No
If no, provide details of all Tickets and/or Accidents for each driver
Current insurance company
Renewal date
*Has there been a Homeowners insurance policy in force continuously for the past 6 months?	(choose one) Yes No
*Has there been a Business Auto policy in force continuously for the past 6 months?	(choose one) Yes No
If no, how long has  there been a lapse of coverage?	(choose one) 10 days or less More than 10 days More than 30 days

Coverage Information:

*Limits of Liability	(choose one) 25/50/25 50/100/50 100/300/100 250/500/100 55,000 Combined Single Limit 100,000 Combined Single Limit 300,000 Combined Single Limit 500,000 Combined Single Limit 1,000,000 Combined Single Limit
*Personal injury protection $	(choose one) No coverage 2,500
*Uninsured/underinsured motorist $	(choose one) No coverage 25/50/25 50/100/50 100/300/100 250/500/100 55,000 Combined Single Limit 100,000 Combined Single Limit 300,000 Combinded Single Limit 500,000 Combined Single Limit 1,000,000 Combined Single Limit
*Comprehensive deductible $	(choose one) No coverage 50 100 200 250 500 1,000
*Collision deductible $	(choose one) No coverage 250 500 1,000

Vehicle Information: 

Vehicle 1
*Year
*Make (Manufacturer)
*Body Type	(choose one) Passenger Auto 1/2 Ton Pick Up 3/4 Ton Pick Up 1 Ton Pick Up Standard Van Step Van Truck Flat Bed Stake Bed Dump Truck Other, please describe in comments
Model
*Gross Vehicle Weight	lbs (Vehicle weight + carrying capacity)
*Cost new	$
*Actual Cash Value	$
*Radius of Operation	(choose one) under 50 miles 51-100 miles 101-200 miles 201-250 miles 251-300 miles 301-500 miles over 500 miles
*Use of Vehicle	(choose one) To and From less than 3 job sites per day Delivery Hot Shot Delivery_subject to time constraints Long Haul Trucking_over 300 mile radius Sand and Gravel Hauling Other, please describe in comments
garaging county
*Do you want Collision coverage for this vehicle?	(choose one) Yes No
*Do you want Comprehensive coverage for this vehicle?	(choose one) Yes No
Vehicle 2
Year
Make (Manufacturer)
Body Type	(choose one) Passenger Auto 1/2 Ton Pick Up 3/4 Ton Pick Up 1 Ton Pick Up Standard Van Step Van Truck Flat Bed Stake Bed Dump Truck Trailer, please describe in comments Other, please describe in comments
Gross Vehicle Weight	lbs (Vehicle weight +  carrying capacity)
Cost new	$
Actual Cash Value	$
Radius of Operation	(choose one) under 50 miles 51-100 miles 101-200 miles 201-250 miles 251-300 miles 301-500 miles over 500 miles
Use of Vehicle	(choose one) To and From less than 3 job sites per day Delivery Hot Shot Delivery_subject to time constraints Long Haul Trucking_over 300 mile radius Sand and Gravel Hauling
garaging county
Do you want Collision coverage for this vehicle?	(choose one) Yes No
Do you want Comprehensive coverage for this vehicle?	(choose one) Yes No

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.