Property/Inland Marine Questionnaire Brochure

PROPERTY/INLAND MARINE INSURANCE QUESTIONNAIREPlease return this form by fax, mail, or email.If you have multiple locations needing property coverage, please send a separate survey for each location.7. Central station burglar alarm?Yes No9. Fire sprinklers?Yes NoI n s u r a n c e a n d R i s k C o n t r o l S o l u t i o n s f o r E n v i r o n m e n t a l S e r v i c e F i r m sCA Lic# 0821383P. O. B o x 7 9 3 Te t o n Vi l l a g e W Y 8 3 0 2 5 8 0 0 . 7 4 6 . 0 0 4 8 t o l l f r e e 3 0 7 . 7 3 3 . 7 4 3 9 f a x w w w. v a n o p p e n c o 2 . c o mP.O. Box 793, Teton Village, WY 83025800.746.0048 toll free • 307.733.7439 fax • www.vanoppenco2.comInsurance and Risk Control Solutions for Environmental Service Firms5. Building construction type (e.g. frame, concrete, brick):2b. City, State, Zipcode:2a. Principal Business Address:1. Company Name:8. Describe security for your property or contractors equipment (e.g. Security service, locked fences, etc):6. Describe adjacent occupants in your building and adjoining buildings: 4. Number of stories in building:3. Age of Building:10. Please identify your Property insurer for the past three years:Effective Date (mm/yyyy) Insurer Premium ($) Expiration Date (mm/yyyy)1231 of 212. List any claims or losses to property within the past five years:If “yes,” please describe: Additional information requested – Please send the following:1. A copy of the Declarations page of your most recent policy (pages reflecting policy effective dates, coverage limits and deductibles)2. A breakdown of values and detail for field equipment, contents/stock, electronic data processing equipment, other propertyI CERTIFY THAT THE STATEMENTS ABOVE ARE CORRECT AND TRUE.Signature over printed name of person completing the questionnaire:Phone Number (ex: 000-000-0000):E-mail:Date (mm/dd/yyyy):11. Separate General Liability coverage maintained? Yes No13a. Would you like a quote for special equipment which you rent? Yes No13b. Is equipment used underground? Yes NoI n s u r a n c e a n d R i s k C o n t r o l S o l u t i o n s f o r E n v i r o n m e n t a l S e r v i c e F i r m sCA Lic# 0821383P. O. B o x 7 9 3 Te t o n Vi l l a g e W Y 8 3 0 2 5 8 0 0 . 7 4 6 . 0 0 4 8 t o l l f r e e 3 0 7 . 7 3 3 . 7 4 3 9 f a x w w w. v a n o p p e n c o 2 . c o mP.O. Box 793, Teton Village, WY 83025800.746.0048 toll free • 307.733.7439 fax • www.vanoppenco2.comInsurance and Risk Control Solutions for Environmental Service Firms2 of 2 1 Company Name: 2a Principal Business Address: 2b City State Zipcode: 3 Age of Building: 4 Number of stories in building: 5 Building construction type eg frame concrete brick: 6 Describe adjacent occupants in your building and adjoining buildings: 7 Central station burglar alarm: 8 Describe security for your property or contractors equipment eg Security service locked fences etc: 9 Fire sprinklers: Effective Date mmyyyy1: Insurer1: Premium 1: Expiration Date mmyyyy1: Effective Date mmyyyy2: Insurer2: Premium 2: Expiration Date mmyyyy2: Effective Date mmyyyy3: Insurer3: Premium 3: Expiration Date mmyyyy3: 11 Separate General Liability coverage maintained: No_3: 12 List any claims or losses to property within the past five years: 13a Would you like a quote for special equipment which you rent: No_4: 13b Is equipment used underground: No_5: If yes please describe: Phone Number ex 0000000000: Email: Date mmddyyyy: Clear Form: