Warren G Bender Insurance Company Sacramento

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General Info & Businessowners(Property and General Liability)
*Name & DBA: How did they hear about us?:
*Address: *Office Phone:
Cell: *Email:
Total Annual Sales:
Are employee benefits offered?:   
Type of business(Describe operations):
Business type:


# of Employees: # of Years In Business:
# of Years In Business Mgmt: Office Space:
Year Built: Sprinklers In Building:   
Alarm:

Business Personal Property Limit: Tenant Improvements:
Building Limit: Sq ft. of Space Occupied:
Sq ft. of Entire Building: Type of Roof:
Building Type:



If over 20 years old-list applicable updates:
If over 20 years old, is the wiring aluminum or copper?:   
Is wiring on circuit breakers:   
Last any claims in last five years:   
Current insurance Carrier:
Current Premium:
Remarks:

Workers’ Compensation

Total Annual Payroll:      # of Fulltime Employees:
# of part-time employees: FEIN #
Any prior coverage cancelled or non-renewed in the last 3 years (other than for non-payment of premium ):   
If applicable, list excluded officers (Name and Title):
List any claims in last five years:   
Current carrier: Current Premium:
Current X Mud:
Remarks:
Business Auto
Who currently handles your auto insurance?:   
Expiration Date:

# Driver Name D.O.B License #
1
2
3
4
5

# Veh Vin # Comp/Coll Ded#
1
2
3
4
5

Liability Covg: Non-owned & Hired:
Med Pay: UM Cvg:
How are the vehicles registered:
Additional Insured/Loss Payees:
Any vehicle used by family members?:   
Any vehicles used by others?:   
Are there any drivers not covered by workers comp?:   
Are any vehicles customized, altered or have special equipment?:   
Do any vehicles transport hazardous materials? :  
What is your current premium:
Any coverage declined/nonrenewed in last 3 years:   
Remarks, Claims, Accidents or Violations in last 5 years:
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Northern California Headquarters
516 Gibson Drive, Suite 240, Roseville, CA 95678
Phone: (916)380-5300 | Fax (916)380-5206 		© 2012 Warren G. Bender Co. All Rights Reserved.