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	Eligibility Questions
	ELIGIBILITY AND PROGRAM INFORMATION

1	0	Is your business based in an area other than your residence (residence includes outbuildings within 100 feet)?	0

2		Have you had more than two claims of any type, related to your business operation, in the last three years?

3		Have you had a single claim, related to your home business, for more than $25,000 in the last three years?

4		Do you own any business under the same legal name as the "Business Name" shown, which is permanently operated from a second location?

5		Do you repackage food or personal care products to be sold under your own label?

6		Are you involved in the sale or manufacturing of explosives or propellants and/or use of flamable liquids?

7		Do you install any products, excluding the installation of computer systems, office equipment, security devices or interior window treatments?

8		Is your business operated by someone other than yourself and/or another immediate family member who resides in your household?

9		Did your gross annual sales/receipts from your business pursuits for the most recent calendar year exceed $250,000 for sale of merchandise or $500,000 for a service business?

10		Total estimated annual revenues

11		Estimated annual revenues from your manufactured products or imports?

12		Do you employ more than ten(10) employees, other than independent contractors or distributors?

13		Is your dwelling located within 1,500 feet from the seacoast on the Gulf of Mexico or the Atlantic Ocean? (N/A in RI)

14		If you are a teacher or tutor (rather than a personal fitness trainer), do you provide instruction for sports, physical education, industrial arts, or martial arts?

15		Do you perform any vehicle repair services (other than oil changes, oil filter changes, or glass repair

	APPLICANT INFORMATION Please answer each question completely.

16		Desired Effective Date:
17		Named Insured:
18		Business Name:
19		Phone:
20		Address:
21		City:
22		County:
23		State:
24		Zip Code:
25		Email:
a		Business Start Date:
b		Years in Business:
c		Years of Experience:
d		Full-time Employees:
e		Part-time Employees:
f		Business Description:
g		Industry Group:
h		Tax ID or SS Number:
i		Gross Receipts:
25		Construction:
26		Business Entity
27		Description of Business to be Insured:


	LIMITS/COVERAGE REQUESTED
28		Property (No Building Coverage) Business Personal Property (BPP) on premises and while temporarily off premises. Must equal 100% of replacement costs. BPP Coverage Limit Requested:
29		General Liability Business Liability each occurrence: (Medical payments of $5,000 each person included)
30		Deductible Standard Deductible is $250 (No other deductible available)

	OPTIONAL COVERAGES
31		Electronic Data Processing Equipment, Data & Media: (EDP coverage)		$ (Maximum limit of $25,000. The sublimit for off-premises EDP coverage is $5,000. No other policy limit may be added to this sublimit.)

32		Money & Securities (On/Off Premises):

	ADDITIONAL INSURED/LOSS PAYEE INFORMATION
33		Loss Payee
		Please enter the number of additional insured in the appropriate fields below:
34		Controlling Interest in this business:
35		Co-Owner of Insured Premises:
36		Manager or Lessor of Premises:
37		Lessor of Leased Equipment:
38		Owner or Lessor of Leased Land:
39		Grantor of Franchise:
40		State/Political Subdivision: (for permits relating to the premises)
41		Dispatcher or Referral Service:
42		Total number of additional insured:

		Comments:

Eligibility Questions