Trahin Miller Insurance Services

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(800) 925-1456 Fax# (317) 489-4401 email: roger@trahinmiller.com

Bakery Insurance Program
BASIC FACTS SHEET

QUICK QUOTE QUESTIONNAIRE
General Information
Business Name:
Employer’s FIN#:
Mailing Address:
City:
State:
Zip:
Contact Name:
Email (or Cell):
Phone#:
Fax#:
Website:
Business Type:
Individual
Partnership
Corporation
LLC
RBA Member:
Yes
No
# of Years in Baking
Desired Policy Effective Date:
Current Insurance Company
Property Information
Check if same as mailing address
Property Address:
City:
State:
Zip:
Is this location within 15 miles of the Atlantic or Gulf Coast:
Yes
No
Year Built:
Type:
Brick
Frame
Steel
Non-Combust
Updates (Year):
Roof
Heating
Electrical
Plumbing
Square Footage You Occupy:
Sole Occupied:
Yes
No
If no, list occupants:
Sprinklers:
Yes
No
Building Limit :
(if owner)
Business Personal Property Limit:
Deductible:
Deep Fat Frying:
Yes
No
If yes, describe fire protection system
(ie. ansul) :
Store Hours :
Liabilty Limit Desired:
Flood (Up to $100,000):
Yes
No
Earthquake (up to $100,000) :
Yes
No
Annual Sales :
Retail% :
Wholesale% :
Deli%:
Catering% :

Do you have a restaurant, table
service or eat in area
(please explain):

Work Comp: (Exp Mod)
(if known):
Payroll Bakery :
Retail :
Clerical :
Owners/Officers Excl from Workers Comp:
Yes
No

Officer's Names:

# FT EE’s :
# PT EE’s :
Business Auto
Rental Car Coverage?
Yes
No
Drive-other-car?
Yes
No
Vehicle #1 :
Vehicle #1 VIN Number :
Deductible Comprehensive:
Deductible Collision:
Vehicle #2 :
Vehicle #2 VIN Number :
Deductible Comprehensive:
Deductible Collision:
Driver #1 :
 
Name :
Date of Birth :
Driver's License#:
State Licensed:
Driver #2 :
 
Name :
Date of Birth :
Driver's License# :
State Licensed :
UMBRELLA LIABILITY:
$1M
$2M
$3M
$4M
$5M
Any claims (losses) in the last 5 years: (premium-to-claim ratio must be 40% or less) Explain:
Additional Informaton, Comments or other Coverages desired


I understand this “Basic Facts” data sheet provides minimum underwriting information for a preliminary price indication. Final Approval and rates can only be determined after a completed application is submitted with “loss runs” and Workers Comp Experience Mod worksheet.

I hereby declare that the statements made in this form are complete and true. The submission of this form does not bind coverage or guarantee rates.