Colton, Downey & Associates, Inc.


	1122 Veterans Drive, Jacksonville, IL 62650 217-243-8484 FAX 217-243-3301 109 Morse, Roodhouse, IL 62082 217-589-5890 FAX 217-589-4925

Home, Auto, Boat, Mobilehome, Motorcycle, Rental Dwelling, and more.

As Business Grows, and You Start To Have Insurance Woes, Call The Pros

24 Hour Claim Services

BEPB Questionaire
Independently Run Facilities -

Effective Date:
Facility #:
Named Insured:
Business Name:
Street:
Street 2:
P.O. Box:
City:
State:		Zip:
Phone:
Email:
Fax:

Business Consultant:

Site Location:
Street:
City:
State:		Zip:
Any satellite locations?			Y	N
If yes, we will contact you for additional locations

Property:
Inventory:	$
Freezer Inventory:	$ (For cafeteria sites only)

Liability:
49619	Vending Machines		$
18435	Stores		$
16823	Cafeteria		$
11288	Delicatessens*		$
*With cooking?			Y	N
*Number of seating?

Workers Compensation
Federal ID # OR Social Security #
Estimated Annual Payroll: $
Sole proprietor: Include Exclude
# of employees:


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