Key Man Insurance

If you (and/or any other individual) are so critical to the operation of your business that it cannot continue in the event of your illness or death, you should consider "key man" insurance. This type of policy is frequently required by banks or government loan programs. It also can be used to provide continuity in operations during a period of ownership transition caused by the death or incapacitation of an owner or other "key" employee.

General Information:

1.	*First Name:
2.	*Last Name:
3.	*Phone:
4.	*Email:
5.	Address:
6.	Address:
7.	City:
8.	*State:
9.	*Zip Code:
9.	County:

The following questions concern the type of business insurance coverage you are requesting . Please answer them as accurately as possible.
1) Description of the business:

2) What type of entity is your company?

3) Please indicate the state in which your business is located:

4) What is the date of incorporation?

MM/YY

5) Please indicate your total number of full-time employees:
(If Sole Proprietor enter 1)

6) Please indicate your total number of part-time employees:
(If none please enter 0)

7) Please indicate your total annual revenue:

8) Please indicate your total annual payroll:

9) Do you currently have KEY MAN insurance?

Yes No

10) If you are currently insured, please select your current insurance carrier:

11) If your provider is not listed above, please provide the company name here:

12) How many years have you had coverage with this company?

13) How many years have you had continuous coverage (With no lapse)?

14) Number of individuals to be quoted?

15) The following questions concern the type of life insurance coverage you are requesting . Please answer them as accurately as possible.
	Name of insured:	Title	Age:	Smoker?	Coverage Amount?
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6	Best Time To Contact: