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
HO-APP-1 (1-00) Page 2 of 2
18. Do you Install any products? Yes No
If Yes, explain:
19. Loss Payee name and type as related to the business operation:
20. Business Personal Property Amount: $
Actual Cash Value Replacement Cost (check one)
(Note: The loss settlement type must be the same as the basic Homeowners)
21. General Liability—Limits of Liability: $
per Occurrence (must be the same as the basic Homeowners).
$
Aggregate
22. Medical Payments—Limits of Liability $
Each Person
$ Aggregate
This questionnaire does not bind YOU nor US to complete the insu
rance, but it is agreed that the information herein shall
be the basis of the contract should a policy be issued.
APPLICANT SIGNATURE:
_________________________________________________________ DATE:
IMPORTANT NOTICE: As part of our underwriting procedure, a ro
utine inquiry may be made to obtain applicable
information concerning character, general reputation, personal characteristics and mode of living. Upon written request,
additional information as to the nature and scope of the report, if one is made, will be provided.