Business Name Click here to enter text.
Mailing Address Click here to enter text.
Contact Name Click here to enter text.
FEIN # Click here to enter text.
DBA Click here to enter text.
*Hours of operation Click here to enter text.
Business Website Click here to enter text.
Phone Number Click here to enter text.
Email
Fax
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Years In Business Click here to enter text.
Years’ experience owning or managing a convenient store Click here to enter text.
Business Type ☐ Individual ☐ Corporation ☐ Partnership ☐ Other, Explain: Click here to enter text.
Preferred Method of Payment ☐ Annual ☐ Semi Annual ☐ Monthly ☐ Automatic Bank Draft
*Property Address
Building is: ☐
Value of
Owned
Awnings/Canopies
☐ Leased
Value of Gas
Pumps
Year Built
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Square Feet of
Building
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Value of sign
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Value of
Building
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Value of Business
Personal Property
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Building Condition
☐ Poor ☐ Average ☐ Good ☐ Excellent
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Building Construction
☐ Frame (siding) ☐ Metal ☐ Brick on Frame (Brick Veneer)
☐ Solid Masonry (Cinder blocks)
☐ Joisted Masonry (Wood Joists/Ceiling or Floor)
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Slab
Pier & Beam
Foundation Type
Buildings Older Than 25 Years Only
1.
Has electrical been updated in the last 25 years?
2.
Has additional capacity been added from the outside?
3.
Have new breaker boxes and wiring been added?
4.
Has the roof been updated in the last 25 years?
5.
Has the heating/cooling system been updated in the last 25 years?
Please describe the extent of all updates: Click here to enter text.
Any buildings greater than two stories high?
Yes No
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Year
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1.
Is Smoking confined to break rooms and designated outside areas with proper metal /non-flammable ashtrays?
2.
Are there any permanent fixtures, equipment, or coolers powered by extension cords?
3.
Are any portions of the premises vacant?
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If yes provide total sq. ft. and length of vacancy.
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4.
Are fire extinguishers mounted, accessible, charged, and serviced annually?
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Number of extinguishers Click here to enter text.
5.
Is there any burning on premises?
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If yes, elaborate: Click here to enter text.
6.
Is there an automatic sprinkler system:
7.
What percent of the building is sprinklered?
☐ 90-100% ☐ 50-89% ☐ Less than 50% ☐ Unknown
8.
If less than 90% of the building is sprinklered, what portion is sprinklered?
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9.
Age of sprinkler system:
☐ Less than 10 years ☐ 10-25 years ☐ 26-49 years ☐ 50 or more years
10.
Type of sprinkler system ☐ Wet ☐ Dry ☐ Other
Please describe: Click here to enter text.
11.
Was the sprinkler system designed for present occupancy?
12.
Is a subcontractor responsible for sprinkler system inspection, testing and maintenance?
☐ Self-maintained
13.
How often is the sprinkler system maintenance and inspection performed?
☐ Monthly ☐ Quarterly ☐ Semi-Annually ☐ Annually ☐ Unknown
14.
Are sprinkler alarms installed?
Are they: ☐ Water Flow ☐ Valve Closure ☐ Unknown
*15.Please check all types of protection at the premises:
☐ Local Alarm ☐ Burglar Alarm ☐ Heat Detection ☐ Fire Extinguisher ☐ Unknown
☐ Central Station Alarm ☐ Full Perimeter Intrusion Alarm ☐ Motion Detection
☐ Smoke Detection ☐ Other
15.
Is there any security staff on premises?
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Are they: ☐ Employees ☐ Contractors ☐ Unknown
 Are they: ☐ Armed ☐ Unarmed ☐ Unknown
16.
Is there a closed Circuit TV system?
17.
Are there any flammables, aerosols, propane or other chemicals stored on the premises?
If yes please describe: Click here to enter text.
18.
What is the square footage of your storage facility or warehouse?
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19.
What is the approximate distance to the nearest fire-station?
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20.
What is the approximate distance to the nearest fire-hydrant?
☐ 1-500 ft. ☐ 501-600 ft. ☐ 601-1000 ft. ☐ 1000-2000 ft. ☐ Greater than 2000 ft.
*1. Do you have grease or grill cooking exposures?
2.
Please list the cooking appliances in place (including smokers) and type of fire
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suppression system if answer is No on #1 above: Click here to enter text.
3.
Is there a UL300 compliant fire suppression system in place over all cooking areas?
 If no, please describe the fire suppression equipment below.
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4.
Is the system serviced twice a year on a contracted basis?
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Please attach copy of last service report.
5.
Date of last service.
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6.
Is there a Class K (wet chemical) fire extinguisher in all cooking areas?
7.
Is there a contracted cleaning program established for the hood and ventilation system and flues?
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Number of times flues cleaned per year: Click here to enter text.
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Date of last professional cleaning: Click here to enter text.
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Number of times the filters/screens cleaned per month:
1.
Are there doors and covers on the compressor electrical boxes and switches?
2.
Is there dust and oil build on the compressors, switches, and electrical boxes?
3.
Is there a prevention maintenance program in place?
 Number of service visits per year: Click here to enter text.
 Name of the maintenance company: Click here to enter text.
1.
Is there any living quarters on the premises?
2.
Are there any non-grocery occupancies on the premises?
3.
Are there any large amounts of space dedicated to the non-retail area or other occupancies? If yes what is the square footage of non-retail space?
Please describe the exposure (include square footage and occupancy):
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1.
Estimated Annual receipts from all operations (excluding gasoline) Click here to enter text.
2.
Total annual receipts for # of Gallons of Gas Sold: Click here to enter text.
*3. How many gas pumps are on the premises?
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*4. Do you haul fuel?
*5. Please check any of the following exposures that apply:
☐ Sales of LP Gas ☐ Full-service gas sales ☐ Self-service gas sales
☐ Auto service/repair ☐ Car Wash operations ☐ Firearms on premises
☐ Check cashing ☐ Drive Through ☐ Delivery Services
☐ More than 15% of store receipts are from operations other than convenience
☐ store, self-service gas sales, and restaurant operations
6.
Is there any mixing, blending, repackaging or re-labeling under your company name?
If yes please describe: Click here to enter text.
☐
☐ 7.
Are there any directly imported products?
What type of quality assurance program is in place?
☐ Formal ☐ Informal ☐ No quality assurance program is needed ☐ Unknown
8.
What percentage of inventory is imported?
☐ Under 10% ☐ 10%-25% ☐ 26-49% ☐ 50% or more ☐ Unknown
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9.
What type of quality assurance program is in place?
☐ Formal ☐ Informal ☐ No quality assurance program is needed ☐ Unknown
10.
Is there any assembly, installation, renting, leasing or repair of any products?
Please Describe: Click here to enter text.
11.
What % of revenue is from renting/leasing equipment?
☐ Under 10% ☐ 10%-25% ☐ 26%-40% ☐ %41 or more ☐ Unknown
12.
Does the company sell any of the following (check those that apply)
☐ Ammunition ☐ Automobiles ☐ Fireworks ☐ Guns ☐ Heavy Equipment
☐ None of the above
13.
Are there any delivery services?
Please describe: Click here to enter text.
14.
Is alcohol sold?
What is the policy for identifying age of patrons to ensure they are of legal age for purchasing alcohol?
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15.
Is alcohol consumption permitted on the premises?
16.
Estimated Alcohol Sales Click here to enter text.
17.
Is food sold?
What practices are in place to ensure proper storage and serving temperatures are maintained?
☐ Employee Training ☐ Formal policy ☐ Informal policy ☐ Frequent
Inspection
☐ Hazard Analysis and Critical Control Point (HACCP) program ☐ Unknown
☐ Other Please describe Click here to enter text.
18.
What is the percentage of sales from vending?
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19.
Are independent contractors hired to perform maintenance, repair or other construction work?
20.
Include terrorism coverage?
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Annual Payroll
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#of Full-Time
Employees
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# of Part-Time
Employees
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Experience
Mod.
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Individuals Excluded
Name
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Safety Program:
☐ None
☐ Written policy
☐ Written manual
☐ Injury & Illness prevention program
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Drug Test:
☐ None
☐ Post-accident
☐ Post-offer
☐ Random
Title
Training Topics include:
☐ Safe Lifting
☐ Osha programs
☐ Slip and falls
☐ Crime Prevention
☐ Other Click here to enter text.
Duties
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Hiring:
☐ Written application
☐ In person interviews
☐ Check references on all applicants
☐ Check references sometimes
☐ No reference checks
☐ Background checks on cash handlers
Ownership %
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Safety Training:
☐ None
☐ Informal
☐ Documented
☐ Checklist used
Loss History

My Business has had no claims in the past 3 years unless stated below. Please list claims and losses even if nothing was paid on the claim or if you don’t know how much was paid.
Date of Claim Description of Claim Amount Paid
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Additional Insured Information
If you need to name and Additional Insured, they must be listed below. This should include your landlord or building owner if you lease your building from a person whose name is different than your business name shown above.
Name: Click here to enter text.
Address: Click here to enter text.
City/State/Zip Click here to enter text.
☐ Landlord ☐ Loss Payee ☐ Mortgage Company
☐ Additional Insured ☐ Proof of Insurance Only
Name: Click here to enter text.
Address: Click here to enter text.
City/State/Zip Click here to enter text.
☐ Landlord ☐ Loss Payee ☐ Mortgage Company
☐ Additional Insured ☐ Proof of Insurance Only
Prior Property Policy Insurance
Number of years with Property Insurance Click here to enter text.
Current Insurance Company 2 nd Prior Year
Company Name Click here to enter text.
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Policy Number
Policy Expiration
Annual Premium
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3 rd Prior Year
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Prior General Liability Insurance
Number of years with General Liability Insurance Click here to enter text.
Current Insurance Company 2 nd Prior Year
Company Name
Policy Number
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Policy Expiration
Annual Premium
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3 rd Prior Year
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Company Name
Prior Worker’s Compensation Insurance
Number of years with Worker’s Compensation Insurance Click here to enter text.
Current Insurance Company 2 nd Prior Year 3 rd Prior Year
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Policy Number
Policy Expiration
Annual Premium
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