Textron Financial: Insurance Form

A diversified commercial finance company providing finance programs for Textron manufactured products.

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TBS Insurance Agency Services,Inc.

If you are interested in a free no-obligation insurance quotation for your business, please complete this form or call us at 800-311-1964. Please complete all sections.

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Have you read Textron Financial's privary policy?:

Yes No

Please indicate your areas of interest

Your Name:

Phone Number:

Fax Number:

Your E-mail:

Website Address:

Your Company Name:

Your Company Mailing Address:

Your Company Physical Address:

(Include County:)

City:

ST: Zip:

Corporation Partnership Individual Other (If other,please specify in comments section)

Number of Years in Business:

Brief description of your business:

Do you offer the following: (If yes,please note annual sales for each and explain the operation.)
Rentals
Leases
Repairs
Lessons
Sales of used inventory/equipment
Other

Total Annual Sales/Receipts:

Total Payroll:

Value of your Business Personal Property (excluding inventory):

Value of your Inventory:

Value of personal property of others in your care,custody or control:

Total number of employees:

Who is your insurance carrier?:

Expiration Date:

Policy Number:

Have you had any claims in the past five years:

If yes,please provide:

Date	Amount	Description

1. Are you a subidiary of another entity or do you have any subidiaries?:

YesNo

2. Is there a formal safety program in operation?:

YesNo

3. Any exposure to flammables,explosives,chemicals?:

YesNo

4. Any catastrophe exposure?:

YesNo

5. Any policy or coverage declined,cancelled or non-renewed during the prior 3 years? Not applicable in MO.?:

YesNo

6. Any past losses or claims relating to sexual abuse or molestation allegations,discrimination or negligent hiring?:

YesNo

7. During the last ten years,has any applicant been cinvicted of any degree of the crime of arson?:

YesNo

8. Any uncorrected fire code violations?:

YesNo

9. Any bankruptcies,tax or credit liens against the applicant in the past 5 years?:

YesNo

Submitted by:Title:


General Liability
Limit of liability overall:
Product/completed operations limit:
Medical payments limit:
Questions:
1. Do you install,service or demonstrate products?	YesNo
2. Foreign Products sold,distributed,used as components?	YesNo
3. Research & development conducted or new products planned?	YesNo
4. Guaranties,warranties,hold harmless agreements?	YesNo
5. Products recalled,discontinued,changed?	YesNo
6. Products of others sold or repackaged under applicant's label?	YesNo
7. Products under label of others?	YesNo
8. Vendor's coverage required?	YesNo
9. Does any named insured sell to other named insured?	YesNo
10. Any repairs? If so,what percentage of total sales?	YesNo
11. Any repairs? If so,what percentage of total sales?	YesNo
12. Do you consign units for sale to other retail dealers?	YesNo
If yes,how are they insured?

1. Any medical facilities provided or doctor employees/contracted?	YesNo
2. Any exposure to radioactive/nuclear material?	YesNo
3. Do operations involve storing,treating,discharging,applying,disposing,or transporting of hazardous material?	YesNo
4. Any operations sold,acquired,or discontinued in the last 5 year?	YesNo
5. Any parking facilities owned/operated? Number of spaces	YesNo
6. Is a fee charged for parking?	YesNo
7. Any watercraft,docks,floats,owned,hired of leased?	YesNo
8. Recreation facilities provided?	YesNo
9. Is there a swimming pool on the premises?	YesNo
10. Sporting or social events sponsored?	YesNo
11. Any structural alterations contemplated?	YesNo
12. Any demolition exposure contemplated?	YesNo
13. Have you been active in or are you currently active in joint ventures?	YesNo
14. Is there a labor interchange with any other business or subsidiary?	YesNo
15. Are day care facilities operated or controlled?	YesNo
16. Are service recoreds maintained for up to three years?	YesNo
17. Is there a gasoline storage system? If yes,describe	YesNo
18. If 17 is yes,do you have tanks?	YesNo
19. If yes,do you need UST coverage?	YesNo

Submitted by:Title:

Textron Business Services Agency, Inc is a licensed broker