Business Insurance Supplement Questionnaire Personal Information
Proposed Insured’s Legal Name (First, Middle Initial, Last) Policy Number
Date of Birth
1. Name and address of business:
2. Title, job duties and percentage of ownership, if any:
3. Type of business: Corporation Partnership 4. Purpose of Insurance
Sole Proprietorship
Keyman Stock Purchase Buy/Sell Agreement a. Keyman—Provide details as to why considered key employee.
Other (Please describe.) Other (Please describe.)
b. Buy/Sell Agreement—Is there a written agreement in effect? (Attach if available.) Please complete #5. c. Loan/Credit—Provide name of lender, loan amount, date and purpose of loan.
Questions
Yes
No
d. Other (Provide details.)
5. List other officers and or employees being insured in favor of the company. Name
Title
Insurance in Force
Insurance Applied For
Percentage of Ownership
6. Financial Summary (Attach annual balance sheet and income statement, if available.) Current Year
Last Year
Preceding Year
Business Assets Business Liabilities Business Net Income Proposed Insured Compensation (salary, commission, bonuses) 7. How was the face amount of the application determined?
GBU FINANCIAL LIFE
ICC20-BIS
www.gbu.org | newbusiness@gbu.org PO Box 645949, Pittsburgh, PA 15264-5257 412-884-5100 | 800-765-4428
1
Business Insurance Supplement Questionnaire Questions (continued)
8. Please provide any additional information you feel is important concerning this business insurance.
I understand that this declaration will be relied upon by the Company in determining insurability. I understand that any material misstatement in this declaration, or elsewhere could render the policy, if issued, voidable. I declare that the above answers are true and complete to the best of my knowledge.
Acknowledgement
Fraud Warning. Any person who knowingly presents a false statement in an application for insurance may be guilty of a criminal offense and subject to penalties under the state law.
Signature and Title
ICC20-BIS
Date
2