P.O. Box 14770, Scottsdale, AZ 85267-4770
8475 E. Hartford Dr., Scottsdale, AZ 85255
(480) 991-7889 WATS (800) 848-8860
Fax (480) 948-1394 Toll Free (866) 240-8807
P.O. Box 571770, Murray, UT 84157-1770
5373 S. Green St., Suite 525, Murray, UT 84123
(801)
290-1144 WATS (800) 594-8900
Fax (801) 290-1160 Toll Free (
800) 332-9285
Agent’s E-mail Address____________________ Preferred Method of Correspondence? E-Mail Fax Regular Mail
Applicant’s E-mail Address _________________ Preferred Method of Correspondence?
E-Mail Fax Regular Mail
In Home Business Supplemental Questionnaire
(to be used in conjunction with a Scottsdale Insurance Company or an Accord Homeowner Application)
1. Insured Name:
2. Policy Number (if applicable):
3. Type of Business/Description of Operations:
4. Name of Business:
5. Form of Business: Individual Joint Venture Partnership Corporation
Other, describe:
6. Business Location:
7. Years in Business:
8. Loss History (past 5 years):
9. Prior Carrier:
10. Estimated Annual Sales/Receipts: Current Year $
Prior Years $
11. Number of Employees: Full-Time: Part-Time:
12. Total Floor Space used for the Business Operation:
13. Who Operates the Business?
Do they live in the Household? Yes No
14. Do you operate any other business or any other part of
this business at a different location? Yes No
If Yes, explain:
15. Do you import foreign products or parts for your product? Yes No
If Yes, explain:
16. Do you package or repackage any food or personal care products? Yes No
If Yes, explain:
17. What is the estimated largest value of any single item of merchandise you sell? $
HO-APP-1 (1-00) Page 1 of 2
