Named Insured

Description of Business

Describe your business including the shop, roasting, or wholesale activities.

Business Address

Phone Number

Email Address

Years in Business

If under 3 years please provide additional industry experience.

Current Insurance Renewal Date

Provide all renewal dates for all coverages if different. If you have no coverage type "N/A".

Current Insurance Carrier

If you have no coverage please type "N/A".

General Liability Limits Requested

Annual Revenues?

Annual Payroll?

Number of Employees?

List total Full-Time and Part-time employees.

Business Personal Property Limit

Cost to replace all equipment, fixtures, furniture, merchandise, etc.

Questions or Remarks