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Wolfeboro Office
21 S. Main Street
Wolfeboro, NH 03894
603.569.2515 or 800.759.7579

Portsmouth Office
7 Islington Street Unit 102
Portsmouth, NH 03801
603.766.3733 or 800.759.7579

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2.	Desired Limits: (Each Occurrence / General Aggregate) (other limits may be available upon request)
	$1,000,000/$2,000,000 $2,000,000/$4,000,000
3.	Service: What percentage, if any, of gross receipts/revenues is derived from service and/or installation of products?
4.	Rental: What percentage, if any, of gross receipts/revenues is derived from the rental of any equipment?

5.	Optional Coverages: Please indicate whether any of the following optional coverages are desired: (the limits provided will be the same as the limits chosen in number 1 above).
	Employee Benefits Liability	Yes No
	Liquor Liability	Yes No
	If yes, please provide annual Liquor Receipts	$
	Hired and Non-owned Auto Liability	Yes No
	Stop Gap Liability (ND, OH, WA, WV and WY only)	Yes No
	Limited International General Liability Extension Endorsement	Yes No

6.	Wholesale Applicants ONLY Are all goods manufactured domestically or by a company with a location in the US?	Yes No
	If no, is Imported Products Liability Coverage desired?	Yes No
	If Imported Products Liability Coverage is desired, what are the gross annual sales for foreign manufactured products?	$
7.	Wholesale Applicants ONLY Do you do any repackaging, re-labeling, repair or re-manufacturing of products?	Yes No