PIZZA DELIVERY INSURANCE QUESTIONNAIRE



GENERAL INFORMATION

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BUSINESS INFORMATION

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LOCATION INFORMATION

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INSURANCE INFORMATION

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WORKERS COMPENSATION SECTION


Payroll Information (Full-Time = 30 or more hours per week)

OWNERSHIP INFORMATION

If "Corporation", "Partnership" or "LLC", please list name, title and percentage of ownership for all officers, partners, or members. Total percentages of ownership must equal 100%. NOTE: Only officers with Stock Ownership ("Corporation"), General Partners ("Partnership") or Managing Members ("LLC") can be excluded.

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Any change of the entity, such as incorporation or creation of a partnership should be reported to us immediately. This change could affect your coverage and/or premium

INSURANCE INFORMATION

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WAGE AND TURNOVER DETAILS:

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ANNUAL TURNOVER RATE - divide the number of voluntary separations during the year by the average number of employees during the year and multiply by 100.

BENEFITS INFORMATION

SAFETY PROGRAM:

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APPLICATION COMPLETION

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