Counterpoint Insurance, Inc. Home, Business, Auto, Personal Umbrellas, Insurance in NH

Commercial Insurance Application
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Company Information

Point of Contact
Company Name	TIN #
Years Experience	Years in business
Business Address	Business Type Sole Proprietor Partnership LLC Corporation
Type of Business	Business Owner
Social Security # (format xxx-xx-xxxx)	Date of Birth (format mm/dd/yyyy)
SR22 Yes No	Email Address
Home Phone (format xxx-xxx-xxxx)	Cell Phone (format xxx-xxx-xxxx)
Work Phone (format xxx-xxx-xxxx)	Fax (format xxx-xxx-xxxx)
Vehicle Insurance Carrier	Vehicle Insurance Expires (format mm/dd/yyyy)
Housing Status Own Rent	Homeowner Insurance Carrier
Life Insurance Yes No Interested	Howeowner Insurance Expires (format mm/dd/yyyy)
Employee	Date of Birth (format mm/dd/yyyy)
Employee	Date of Birth (format mm/dd/yyyy)

Coverage Information

CSL Limits	Tool Coverage $
Annual Sales $	# Employees
Building Coverage $	Liability $
Deductible $	Year Built (format yyyy)
Type of Construction	Occupied Square Footage
Updates	Alarm Fire/Burglar Fire Burgler Both
Hired Auto Yes No	Non-Owned Yes No
Exterior Glass Yes No	Exterior Sign Yes No
Employee Dishonesty Yes No	Terrorism Yes No

Vehicle Information

Vehicle 1
Make/Model	GVW
Cost New $
Vehicle 2
Make/Model	GVW
Cost New $
Vehicle 3
Make/Model	GVW
Cost New $
Full Coverage Now Yes No	Bodily Injury Split Limits
CSL Limits
Property Damage Limits	Medical Payments
Vehicle 1
Comp/Other than collision $	Collision $
Towing and Rental $
Vehicle 2
Comp/Other than collision $	Collision $
Towing and Rental $
Vehicle 3
Comp/Other than collision $	Collision $
Towing and Rental $
Please include Data and details of Violations and Accidents
Driver Violations	Driver Accidents
Driver Violations	Driver Accidents
Driver Violations	Driver Accidents