BUSINESS OWNER QUESTIONNAIRE
Please, fill out the form completely ( * Required field in order to process)

Have you received a quote from us before? Yes No   If yes, please provide Quote #: (usually 5 to 9 digits)
*Name:     Phone:     Fax:
*Email:     *Please type your email again:
*Business Name:   *Business Phone:   Type of Business:
Business Address: (including full address and zip code, No PO BOX):
Mailing Address: (including full address and zip code, No PO BOX):
Years in Business:   Experience in Field:   Years at location:
FEIN or Social Security #:
Improvements & Betterments Limit: $   Personal Property Limit $
Annual Income $
Age of Building:     Construction: Frame Brick Steel
# of Stories:    Type of Roof:
Smoke Detectors? Yes No                Fire Alarm:             Yes No                Burglar Alarm?    Yes No
Central Station?     Yes No                Fire Extinguishers? Yes No                Roll Down Gate? Yes No
Other Occupants in Building:      Sq Ft you occupy:
Any product(s) sold or repackaged under your company name? Yes No    If yes, describe:

# of Owners:     # of Employees Full Time:     # of Employees Part Time:
Payroll: $     Food Gross Receipts: $
Liquor/Beer Total Gross Receipts: $    Office Hours:     # of Days:

Current Insurance Company:
Current Premium:
5 Year Loss History:
Any Bankruptcy: Yes No     Current Liability Limit:

Additional Insured: Landlord Managing Agent Leasing Company
Full Name and Address:

Other important information we should know:

E mail:  Larisa Ayzina,  layzina@bfbond.com
Telephones (800) 921 1008 /  (212) 566 1881 Ext.114
Address 2 John Street suite 201  New York, NY 10038
www.bfbond.com