Short Insurance Form

Short Insurance Form

Applying for insurance??? Fill out this questionnaire! Form Preview
  • Short Form Questionnaire

    For informational purposes only
  •   Country Annual Sales No. of Buyers
    1.
    2.
    3.
    4.
    5.
    6.
    7.
  •   Current Year to date Calendar Year 2016 Calendar Year 2015 Calendar Year 2014
    Period (indicate if different than the above headings)
    Insurable Sales
    Total Value of all Sales
    Largest Bad Debt
    Number of Losses
  •   Range Credit Limits # of Customers
    Over $250k
    $100-$250k
    $50k-$100k
    $25k-50k
    $10-$25k
    Under $10k
  •   Total Amount Outstanding
    Current - Not yet due
    1-30 days
    31-60 days
    61-90 days
    Over 90 days
  •   Amount
    Quarter Ending 3/31
    Quarter Ending 6/30
    Quarter Ending 9/30
    Quarter Ending 12/31
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