R.R.I.S. Live Asset Questionnaire

        GENERAL INFORMATION:        Please provide the following contact information:    Sheri Ritchie or Victor Vieira

 (The Referral Agent is the name of your Insurance Agent in our office or how you became aware of our website)

First Name
Last Name
Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
FEIN# or Social Security No.
Work Phone
FAX
E-mail
URL

        Please provide a detailed description of your operation:

Please list additional locations here:

       What year was your business established?

        Business Entity Type:

Sole Proprietor/Individual
Corporation
Partnership
LLC
Other

        Type of Business/Property? Please select the appropriate description of your business or property:

Grower  Tree Farm  Nursery, Greenhouse, etc.    Arboretum or Botanical Garden   Homeowner Association  
Fruit/Nut Producer (Orchard, Vineyard, etc.) Golf Course  Residential Property  College/University                                    

   Hotel/Motel/Inn   Municipality  Cemetery  Office Park or Retail Center  Plantation  Resort  Zoo                                                            

Other Type                                                                  

        How many part time employees?   

How many full time employees? 

        Name of current/prior insurance carrier:

        What is/was the policy period?

        Any operations sold, acquired, or discontinued in the last five (5) years?

Yes
No

        If there have been any claims in the past five (5) years, please describe, including date of loss and amount paid.

        Do you have any subsidiaries or are you a part of another business?

Yes
No

       Deductible desired ($10,000 minimum)? 

        What were your gross sales the past 12 months?

        What will your gross sales be over next 12 months?

        Are either of the following hazards adjacent to the assets which will be insured?

Excessive brush area
Forest
Uphill water retention ponds

If so, please describe:

        Do you have back-up power supplies for all greenhouses and/or irrigation systems?

Yes     No

        Is the property irrigated?  Yes   No

        If yes, describe water supply which is independent from municipal service (e.g. well, retention pond, river, etc)

        If you are a member of an association, please describe (e.g. ANLA, etc.):

        How many acres of property do you have?

        Where did you hear about us?

        After, pressing submit button below, please complete the following  inventory list and fax to our office.  If more room needed, please print this, again, and fax all info (referenced to your name):

    IF MORE SPACE NEEDED, PLEASE PRINT OR COPY THIS AREA IN ORDER TO CONTINUE YOUR LIST.