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TRIREME INSURANCE SERVICES, INC
Commercial Liability and Property Insurance Questionnaire

Tel:626-653-0708 Fax:626-653-0707
WEBSIDE: WWW.FORBUSINESSINSURANCE.COM

NAME OF THE COMPANY: *
MAILING ADDRESS: *
CITY: *    
STATE: * ZIP CODE: *
TEL: * FAX:
PERSON CONTACT: *
NATURE OF BUSINESS:
CORPORATION    INDIVIDUAL    OTHERS    
YEARS IN BUSINESS?
MAIN PRODUCTS


SECTION ONE: OPERATION INFORMATION
IMPORTER ? YES    NO    
TOTAL ESTIMATED ANNUAL SALE ? $
TOTAL NUMBER OF EMPLOYEES ?
ARE PRODUCTS UNDER YOUR OWN LABEL? Y    N    


SECTION TWO: PREMISE INFORMATION
BUILDING YEAR ?
AREA OF YOUR OFFIC ? SQ.FT
TYPE OF BUILDING? MASONRY    STUCCO    OTHER    
HOW MANY FLOORS?
ANY SPRINKLERS IN THE BUILDING? Y    N    


SECTION THREE: YOUR BUSINESS PERSONAL PROPERTY
BUSINESS PERSONAL PROPERTY REQUESTED FOR INSURANCE $
ANY CENTRAL ALARM SYSTEM FOR YOUR OFFICE? Y    N    


SECTION FOUR: THE PRIOR INSURANCE INFORMATION
DO YOU HAVE ANY PRIOR INSURANCE? Y    N    
PRIOR INSURANCE NAME?
EXPIRATION:   ANY CLAIM OR LOST ? Y    N    
DATE OF LOST:    AMOUNT PAID $
REASON OF LOST:


SECTION FIVE: DETAIL DESCRIPTION OF YOUR BUSINESS OPERATION
PROPERTY LOCATION ADDRESS: *
 
        


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