RiskNet Application

Fields with * are mandatory

Coverages Sought:

Property & General Liability	Yes    No
Employment Practices Coverage	Yes    No
Directors & Officers and Company Coverage	Yes    No
Fiduciary Coverage	Yes    No
Crime Coverage	Yes    No
Technology, Media & Professional Services Coverage	Yes    No
Miscellaneous Professional Services Coverage	Yes    No

Address
City
State	Zip
Website
Phone
Fax
Contact Name
Contact Title
Years in Business
Number of Employees
FEIN
Description of Business
Gross Revenues Last Year
Gross Revenues Expected This Year
Non U.S. Revenues
Total Payroll Last Year
Expected Payroll This Year

Location 1:

Address
City
State	Zip
Age of Building
Number of Stories
Square Footage Occupied
Sprinkler System	Yes    No
Construction of Building
Total Replacement Value of the Business Property
Total Replacement Value of the Computer Equipment
Do you own the building?	Yes    No
If Yes, What is the Building Replacement Cost

Location 2:

Address
City
State	Zip
Age of Building
Number of Stories
Square Footage Occupied
Sprinkler System	Yes    No
Construction of Building
Total Replacement Value of the Business Property
Total Replacement Value of the Computer Equipment
Do you own the building?	Yes    No
If Yes, What is the Building Replacement Cost

Are there additional locations?    Yes    No