Exit Factor Insurance Form - Cennairus Insurance

Exclusive Insurance Solutions for Exit Factor Clients

Brought to you by the partnership between Cennairus and Exit Factor—tailored coverage to protect your business.

Business Information

Legal Business Name

Entity Type

Federal Tax ID Number

Location Address

City

State

Zip Code

Years in Business

Contact Person Name

Contact Number

Email Address

Owner

Name

Ownership %

Title

Included or excluded from coverage?

Owner 2

Name

Ownership %

Title

Included or excluded from coverage?

Owner 3

Name

Ownership %

Title

Included or excluded from coverage?

Employee

Number of Employees

Job Description or Class Code

Annual Payroll

Do you currently have insurance coverage in force?

If yes, please attached all loss runs

Building Information

Do you Own or Lease?

If you lease or own, are you required to have building coverage, what is the amount?

Year Building was Built?

Has the roof been updated?

If Yes what year?

Number of Stories:

Square footage

Sprinkler?

Central Burglar Alarm?

Business Personal Property Coverage Amount (Covers Equipment, Furniture, Fixtures and Inventory that you Own)

Landlord Name

Landlord Address

City

State

Zip Code

Hired and non-owned auto (HNOA) ?

Insurance covers liability for damages caused by vehicles used for business, even if the business doesn’t own the vehicles. This includes vehicles that are rented, leased, or borrowed, as well as employees’ personal vehicles used for business.

Please Upload your Landlords Lease requirements

GL Limits

1M per Occurrence/2M Aggregate 2M per Occurrence/2M Aggregate 3M Per Occurrence/4M Aggregate

Annual Revenue