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Bell Insurance is Servicing Franklin, Adams, and York Counties In Pennsylvania

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Chambersburg Commercial Insurance Application Form

To provide you with the best quote, please complete all the information below.

Company Information

Company Name
Contact Name*	Title
Address
City*	State*	Zip*


Company Website
Telephone:	717-123-4567
Fax:	717-123-4567
Best Time To Call*
E-mail:

Current insurance carrier*
How long*	yrs
Policy effective date
Policy expiration date
Total years with continuous coverage	yrs
Annual Sales
Gross Payroll

Please describe the nature of your business/description of operations.

What type of insurance(s) does your current company carry for you?
(check all that apply)

Property	Automobile	Glass & Sign	AR/Valuable papers	Crime

Tranportation	Equipment Floater	Builders Risk	Electronic Data	General Liability

Truckers/Motor Carrier	Garage & Dealers	Vehicle Schedule	Boiler & Machinery	Workers Comp

		Umbrella

Please provide us with ALL your locations information
(Include Address, whether you own or rent, year building was built, and whether you occupy entire building.)

General Information
(In the "Remarks" box, please explain all "Yes" responses)

Is the applicant a subsidiary of another entity or does the applicant have any subsidiaries?		Yes No
Is a formal safety program in operation?		Yes No
Any exposure to flammables, explosives, or chemicals?		Yes No
Any catastrophe exposure?		Yes No
Any policy or coverage declined, cancelled or non-renewed during the prior 3 years?		Yes No
Remarks:
Why do you wish to change carriers?

Losses Information
(If yes, please provide date of each occurence, insurance line, occurrence description , and the claim status)

Have you had any losses?	Yes No