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Mouton Insurance Brokerge Questi

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					                                 National Insurance Consulting Group, Inc.
                                       Insurance Information Intake
GENERAL INFORMATION

Applicant’s Name:

Mailing Address:

Phone:                                                               Facsimile:

Organizational Structure:
    Individual         Partnership            Corporation        Non-Profit       Other

If other, please explain
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Number of Years in Business:

Name of Organization:

Name & Phone # of Contact for Inspection:

Nature of Business:     Office    Service X Retail   Wholesale   Other____________________________




                                                                                                                     1
Description of Business:
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Indicate Coverage Needed:
  Property               Commercial General Liability     Business Auto        Boiler & Machinery   Worker’s Compensation
  Professional Liability (E&O)

PREVIOUS CARRIER INFORMATION

Name of Carrier:

Policy Type:

Policy Number:

Number of Losses in Last Three Years:

Limits of Insurance:

Premium Amount:

PROPERTY INFORMATION

Construction Type:
  Frame                 Brick                Joisted Masonry              Masonry Combustible       Fire Resistive




                                                                                                                            2
  Location      Square              Street, City, County,           Year Built   Number of        Renovations             Building
                Footage                State, Zip Code                            Floors        Complete & year            Value

 1


 2




 3


 4




CONTENTS INFORMATION

Please list all contents to be insured
  Location              Contents / Valuables                Replacement Cost         Contents / Valuables         Replacement Cost

 1


 2


 3


 4




                                                                                                                                     3
GENERAL LIABILITY
  Smoke Alarms             Sprinkler System               Burglar Alarm             Security Guard
  Manufacturer_____________                               Manufacturer________     Hours ____________

Desired Liability Limit:         300,000      500,000     1,000,000    2,000,000    Other___________________________

Any Hazards:      Yes      No

If yes, please explain:
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Are there any Additional Interest       Yes   No

    Additional Insured     Loss Payee         Mortgagee         Leinholder          Employee as Lessor

Name and Address:



BUSINESS AUTO
  Driver                    Name & Address                            DOB                Year & State License     SS #

1

2

3

4

5


                                                                                                                         4
Vehicle Information
  Veh.       Year        Make, Model, Body type                 VIN #                 Cost     COMP         COLL


1.
2.

3.

4.

5.


Worker’s Compensation
    State             Employers Duties            # Full Time           # Part Time          Remuneration / Salary




                                                                                                                     5
EMPLOYEE BENEFITS

Current Carrier:

Renewal Date:

        Coverage Type               Medical         Medical Renewal       Dental Current        Dental Renewal   Vision Current    Vision
                                    Current                                                                                       Renewal
 Employee (EE)
 Employee & Spouse (ES)
 Employee/Child(ren) (EC)
 Employee Family (EF)

 Life:
 Flat Amount____________________         Multiple of Salary____________       Rates per $1000________________

 Short Term Disability:
 Elimination Period ________Weeks        Benefit Duration_____________        Benefit Amount____________

 Long Term Disability:
 Elimination Period ________Weeks        Benefit Duration_____________        Benefit Amount____________




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Census
                               COVERAGE    HOME            WORK                           COMPANY
         NAME   GENDER   DOB                        DOH             SALARY   JOB TITLE
                                 TYPE     ZIPCODE         ZIPCODE                        OWNERSHIP




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posted:3/10/2010
language:English
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