New Business Information Check List

Please fill in all requested information. You will have an opportunity to print the completed form before it is submitted. If you prefer to fill out the form by hand and submit it by mail or fax, please click here.

Business Name (t/a or dba name):
Corporation Name:
Web Site
Business Address:
Street Address
Address Line 2
City
State
Zip Code
County
Mailing Address (if different than Business Adress):
Street Address
Address Line 2
City
State
Zip Code
County
Business Description:
Days & Hours of Operation:
Business Type: Individual Partnership Corporation C Corporation S LLC LLP
Federal Tax ID:
Phone:
Fax:
Cell:
Contact Person:
Contact Person's Phone Number:
Contact Person's Email:
Number of Years In Business:
Number of Years In Management Experience:
Desired Effective Date of Coverage: / MM / DD YYYY
Building Construction Type: Wood frame with siding Metal roof & walls Brick & Block with wood joists in roof & walls Brick & Block with steel beams in roof & walls Fire Resistive (all steel beams have 1 or 2 hour fire rating)
Year of Construction (or approximate age):
Do you occupy the entire building? Yes No
How many square feet do you occupy?
How many Floors in your building?
Basement? Yes No
If there is a basement, is it finished? Yes No
Fire Sprinklers? (sprinkler heads in ceiling throughout building) Yes No
Alarm System Information – Please circle all that apply: Central Station Burglary Central Station Fire Holdup Video Monitors Smoke detectors
Is there an automatic extinguishing system covering all cooking equipment? Yes No
If yes, answer: Wet Chemical (UL 300) Dry Chemical (NFPA 96)
Are contracts in place for semi-annual cleaning/inspection/maintenance? Yes No
How many portable fire extinguishers are on site?
How many miles to the nearest fire department?
If the building is more than 20 years old, most recent year of electrical renovation:
If the building is more than 20 years old, most recent year of Heating / AC renovation:
If the building is more than 20 years old, most recent year of Plumbing renovation:
If the building is more than 20 years old, most recent year of roof renovation:
How often do you make deposits? Daily 2-3 times per week Weekly
Maximum amount of cash deposited? $ Dollars
How much cash is left on premises overnight? $ Dollars
Is all extra cash kept in a locked safe? Yes No
Average number of full time employees:
Average number of part time employees:
Estimated gross annual Payroll: $ Dollars
Estimated gross annual Sales: $ Dollars
Was insurance cancelled or non-renewed in the past 3 years? Yes No
Prior Insurance Company:
Prior Insurance Policy Number:
Any claims made in the past 3 years? Yes (may need printed loss runs) No
All coverage limits must be at 100% full replacement cost
Amount of Building coverage (or permanent improvements): $ Dollars
Amount of Contents coverage: $ Dollars
Deductible: $250 $500 $1000 $5000
Standard Liability Limit: $1,000,000 occurrence / $2,000,000 aggregate
Umbrella Liability Limit – in addition to above (if needed) $1 Million $2 Million $3 Million $4 Million $5 Million
Money coverage – on premises (maximum): $ Dollars
Money coverage – off premises (maximum): $ Dollars
Employee Dishonesty coverage: $5,000 $10,000 $25,000
Outdoor Signs coverage: $ Dollars
Food Spoilage coverage: $5,000 $10,000 $25,000
Water Backup coverage: $5,000 $10,000 $25,000
Computer hardware coverage: $ Dollars
Computer software coverage: $ Dollars
Exterior Building Glass coverage – how many linear feet? (total width only)
If Restaurant or Bar – Seating Capacity:
If Restaurant or Bar – % alcohol sales:
If restaurant or bar, check any that apply: Delivery Catering Dance Floor Entertainment Bouncer
Please tell us who referred you so that we may thank them:
Officer Information needed for Workers’ Compensation

(To be excluded from workers’ compensation in Maryland, you must be an officer of a close corporation, 20% shareholder of an LLC, or an inactive officer drawing no payroll)
Name:
Date of Birth: / MM / DD YYYY
Social Security Number:
Title:
% Ownership:
Included or Excluded? Included Excluded
Any Additional Interests Required? – Provide full name & address
Landlord Name:
Landlord Business Address:
Street Address
Address Line 2
City
State
Zip Code
County
Mortgagee Name:
Mortgagee Business Address:
Street Address
Address Line 2
City
State
Zip Code
County
Loss Payee Name:
Loss Payee Business Address:
Street Address
Address Line 2
City
State
Zip Code
County
Franchisor / Developer Name:
Franchisor / Developer Business Address:
Street Address
Address Line 2
City
State
Zip Code
County
Will any of the above also be named as an additional insured? Check all that apply: Landlord Mortgagee Loss Payee Franchisor / Developer
Comments:
Your E-mail Address:
STRASCO INSURANCE AGENCY INC.
3 GREENWOOD PLACE SUITE # 307
PIKESVILLE, MARYLAND 21208-2770
PHONE: 410-486-2020 / FAX: 410-486-2077
STEPHEN F. ROSENBERG – PRESIDENT
HENRY I. ROSENBERG – VICE-PRESIDENT

New Business Information Check List

New Business Information Check List

All coverage limits must be at 100% full replacement cost

Officer Information needed for Workers’ Compensation

Any Additional Interests Required? – Provide full name & address

STRASCO INSURANCE AGENCY INC. 3 GREENWOOD PLACE SUITE # 307 PIKESVILLE, MARYLAND 21208-2770 PHONE: 410-486-2020 / FAX: 410-486-2077 STEPHEN F. ROSENBERG – PRESIDENT HENRY I. ROSENBERG – VICE-PRESIDENT

STRASCO INSURANCE AGENCY INC.
3 GREENWOOD PLACE SUITE # 307
PIKESVILLE, MARYLAND 21208-2770
PHONE: 410-486-2020 / FAX: 410-486-2077
STEPHEN F. ROSENBERG – PRESIDENT
HENRY I. ROSENBERG – VICE-PRESIDENT