Street Address:

City:

State:

Zip Code:

Date of Current Policy Expiration (dd/mm/yyyy):

Sales Information:

Annual Gross Sales ($USD):

Cost of Goods Sold ($USD):

Annual Payroll - minus payroll for officers, executives, managers ($USD):

Estimated Number of New Homes Sold per Year:

Estimated Number of Used Homes Sold per Year:

Percent Used Homes more than 7 Years Old:

Any Units Sold over 20 Years old?  Yes   No 

If yes, how many?

Operations Questions:

Build Sheds / Decks / Carports / Garages?  Yes   No 

Refurbish / Repair Used Homes?  Yes   No 

Modular Set-up / Installation?  Yes   No 

Sub-contract Home Delivery, Set-up / Installation (%):

Please list all Property / Liability Claims you are aware of in the last 3 years:

Supplemental Property Information:

Year Built.........Description of Property..................Bldg Limit ($)......Contents($)......Sq.Feet

Business Income/Year ($USD):