1. … an Assurex Partner John Baldwin, Account Executive
P.O. Box 6006
300 Concourse Blvd., Suite 300 Ridgeland, MS 39158-6006
Ridgeland, M.S. 39157-2051
Telephone 601/607-5591
http://www.foxeverett.com Fax 601/607-5691
john.baldwin@foxeverett.com
Please note most of this information can be obtained by making copies of your current policies. In addition a
review of this policy information would help me determine proper coverages for your account. In some cases
the current coverages are correct in other cases they may not be. We not only want to provide you with a
competitive quote on your insurance program we also want to verify that the coverages you currently have are
accurate.
1.) List of Commercial Auto’s including complete VIN#’s, year, make, values and radius of use. None/ use
personal
2.) List of Drivers for vehicles including date of birth, driver’s license number and state. Only myself
3.) List of Equipment with complete serial numbers, values, model, & make. Use rental
4.) List of property to be insured (this would include bldgs & personal property) with values, construction,
and location. N/A
5.) Federal ID # 20-8942824
6.) Renewal Dates for all lines of coverage. Annually
7.) Limits desired on Auto Liability, General Liability, Workers Compensation. 1000000 gen. liability &
workers comp. less than 5 empolyees
8.) General Liability Classifications with updated payrolls, and receipts where applicable. Classifications
would be broken into payroll breakdowns and descriptions of jobs per payroll. Ex Salesman,
management, Warehouse workers etc. Bookkeeper/Secretary 50,000 per year & Myself/owner
52000 per year and sub contracted labor 350,000 per year updated quarterly
9.) If Umbrella coverage is desired? (Desired limit) N/A
10.) Officers of company names, date of birth, title, % of ownership, and whether they are to be included or
excluded on the workers compensation. Trey Carter 100% owner 7/27/79 excluded
11.) Misc. items in warehouse forklifts, etc. N/A
12.) Short narrative of the type of operations you are involved in on a regular basis. On a day to day basis I
spend time ordering material, scheduling, and directly involved in pouring concrete for various
applications.( house foundations, apartment building foundations, parking lots, sidewalks driveways, all
flatwork on the ground)
13.)Loss Runs for all lines G.L., Work Comp, Property, Auto, for 3 years the loss runs need to be current.
Need more info
14.) A list of all entities that involved with a short description of what they do and how they are related.
N/A
2. … an Assurex Partner John Baldwin, Account Executive
P.O. Box 6006
300 Concourse Blvd., Suite 300 Ridgeland, MS 39158-6006
Ridgeland, M.S. 39157-2051
Telephone 601/607-5591
http://www.foxeverett.com Fax 601/607-5691
john.baldwin@foxeverett.com
15.) Number of years in business. New business 8 years experience personally my labor has 50+ years
combined
16.) Number of employees full and part-time. Myself + 1 bookkeeper full time and subcontracted labor
17.) Payroll broken into classifications ex. Clerical, shop, sales, etc. same as question 8
18.) Gross Receipts ? on material I purchase
I look forward to hearing back from you.
John
I hope this is helpful please call with any more questions. I need coverage fairly soon. Thanks look forward to
hearing from you.
Trey Carter
