SALMEN INSURANCE

First & Last Name:	A value is required.	Business Name:	A value is required.
Street Address:		City, State & Zip:
Telephone:	A value is required.	Fax:
E-Mail Address:	A value is required.

	Current Insurance Information
Insurance Company Name:		# of claims:
Any losses in last 3 years?:		Claim amt. pd $:
PremiumAmount:		Policy Exp. Date:
MOD Factor:		Policy #:
Describe the type of Coverage you currently have:

	Prior Carrier Info
Insurance Carrier Name:
# of claims:		Claim amt. pd $:
PremiumAmount:		How many years with:
MOD Factor:		Policy #:
	About Your Business
# of Full-time:		# of Part-time:
Owner's Name:		Fed Tax ID:
License Type:		Yrs in Business:
License #:		# of locations:
Annual Gross Sales:		Square Footage:
Est payroll / mo.:		Type of Business:
Please describe your business here:
	Owners / Partner / Officers
Name	Date of Birth	Title	Ownership %



	Payroll Information
Class Codes	Employee Duties	Annual Payroll $	Hourly Wage $




	General Information
Do you offer safety programs?
Do offer health benefits to majority of employees?
Do employ any minors (under 18)?
Is operation all/part of existing business that was purchased/acq.?
Do you use subcontractors?
Use any equipment that bends/shapes/forms?
Are athletic teams sponsored?
Been a lapse in coverage during past 12 months?
Any work above 15 feet?
Had a bankruptcy in past 7 years?
Are a member of any trade organizations?

	Additional Information
Please provide any additional information that may be helpful in giving you an accurate quote or that you didn't have enough room for.