UNITED FRANCHISE INSURANCE APPLICATION

General Information:

Named Insured:		Contact Person:
Mailing Address		Telephone Number:
Address:		Fax Number:
City:		E-Mail Address:
State:		Web Site Address:
Zip:		Federal ID Number (FEIN):
Legal Entity:	Corp. Individual Joint Venture Partnership LLC LLP	Unemployment Number:
Effective Date:		(MN/NY Only)
Years in Business		Full Time:
Years of Industry Experience:		Part Time:
		What is Your Expiring Premium:
		Insurance Carrier:

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Location 1

Location Address		Year of Updates
Address:		Roof:
City:		Electrical:
State:		Plumbing:
Zip:		Heating:
Do You Own the Building:	Yes No	Sprinklered:	Yes No
Building Limit:		Square Feet:
Business Personal Property Limit		Number of Stories of Building:
Gross Sales Receipts:		Other Occupancies of Building:
Printing Receipts:		Manager of Lessor of Premises
Total Payroll:		Name:
Construction of Building	Frame Non-Combustible Masonry/Non-Combustible Joisted Masonry	Address:
Central Fire Alarm:	Yes No	City:
Central Burglar Alarm:	Yes No	State:
Year Built:		Zip:
Are owners to be included for Workers Compensation Coverage:	Yes No	Fax Number:

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Payment Options:

Direct Bill:

Annual Semi-Annual 33% Down and 3 Equal 25% Down and 7 Equal 25% Down and 9 Equal

A $7 fee applies per each installment.

Loss Summary:

Please forward the three year loss summary to fax number 952-890-0535 or attach it.

Remarks/Additional Information: