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Contact Information:
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First Name:
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Last Name:
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Daytime Telephone:
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Evening Telephone:
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Email:
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Address:
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City:
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State:
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Zip:
Underwriting Information:
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 Are any aircraft owned, leased, chartered or furnished for regular use? Yes No
11
 Do any drivers have mental or physical impairments? Yes No
12
 Are any premises, vehicles, watercraft, aircraft used for business? Yes No
13
 Are any premises, vehicles, watercraft, aircraft owned, hired, leased or regularly used not covered by the primary policies? Yes No
14
 Do you engage ina any type of farming operation? Yes No
15
 Do you hold any non-remunerative positions? Yes No
16
 Do you employ any residence employees? Yes No
17
 Any non-owned property exceeding $1,000 in value in your care, custody or control? Yes No
18
 Any non-owned business or professional activities included in the primary policies? Yes No
19
 Does any primary policy have reduced limits of liability or eliminate coverage for specific exposures? Yes No
20
 Was any coverage declined, cancelled or non-renewed within the past 5 years? Yes No
21
 Any motorcycles, mopeds or all terrain vehicles owned? Yes No
22
 Any other business activities conducted from your residence or premises? Yes No
23
 Please explain any YES answers from above
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 Are there drivers under 25 yrs of age?
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 If yes state how many:
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 What is the number of autos you own?
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 What is the number of recreational vehicles you own?
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 What is the number of single family dwellings you own?
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 What is the number of multi-unit buildings you own?
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 What is the number of vacant property (land) you own?
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 What is the number of motorcycles you own?
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 Where there any losses or claims in the last 5 years? Yes No
33
 If yes, what is the date, amount paid and description of each loss or claim?
34
 What is the liability limit requested?
Social Security #:
Comments or Questions:
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36
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Gordon Insurance Associates, Inc.
8251 West Thunderbird Road, Ste 160
Peoria, Arizona 85381
Office: (623) 486-6815
Fax:     (888) 870-9690
Email: info@giasite.com

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