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Business Name:* Business Address: City: State: Alabama Alberta, Canada Alaska Arizona Arkansas British Columbia California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Manitoba, Canada Marshall Islands Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Brunswick, Canada New Hampshire New Jersey New Mexico New York Newfoundland and Labrador North Carolina North Dakota Northwest Territories Nova Scotia, Canada Nunavut, Canada Ohio Oklahoma Ontario, Canada Oregon Pennsylvania Prince Edward Island, Canada Quebec, Canada Rhode Island Saskatchewan, Canada South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Yukon, Canada Zip: Contact Name:* Contact E-Mail Address:* Contact Telephone:* Paint Supplier, Dist., or Jobber: HazWaste (hauler) disposal company: Paint/Chemical Product Mfg. (primary): 3M Akzo Nobel BASF DuPont Martin-Senour Mathews Matrix PPG Safety-Kleen Sherwin-Williams Spraylat Transtar Valspar OTHER Number of wrk orders(repair orders) per month: < 10 10 - 20 20 - 40 40 - 60 60 - 80 80 - 100 100 + Total No employees: (incl owner/mgrs) <10 11 - 15 16 - 20 21 - 30 31 - 40 41 - 50 50 + Building square footage: < 5,000 5,000 - 10,000 10,000 - 20,000 20,000 - 30,000 30,000 - 40,000 40,000 - 50,000 50,000 + Property square footage: < 5,000 5,000 - 10,000 10,000 - 20,000 20,000 - 30,000 30,000 - 40,000 1-acre > 1-acre Number of owned vehicles (trucks, cars, etc.): 0 1 - 5 6 - 10 11 - 20 21 + *Required field; cannot be left blank If Having Trouble, CALL: 1-888-374-7475

Average gross per work order: < $1,000 $1,000 - $2,000 $2,000 - $3,000 $3,000 - $5,000 $5,000 + Employee payroll cost (per month): < $5,000 $5,000 - $15,000 $15,000 - $25,000 $25,000 - $35,000 $35,000 - $45,000 $45,000 - $60,000 $60,000 - $80,000 $80,000 - $100,000 $100,000 + Est. gross income (per month): < $50,000 $50,000 - $80,000 $80,000 - $100,000 $100,000 - $200,000 $200,000 - $300,000 $300,000 - $500,000 $500,000 + Avg. electric bill (per month): < $500 $500 - $1,000 $1,000 - $2,000 $2,000 - $3,000 $3,000 - $4,000 $5,000 + Avg. gas heat bill (per month): < $300 $300 - $500 $500 - $1,000 $1,000 - $2,000 $2,000 - $3,000 $3,000 + Avg. water bill (per month): < $50 $50 - $100 $100 - $200 $200 - $300 $300 - $400 $400 - $500 $500 - $1,000 $1,000 + Avg. HazWaste bill (per month): < $50 $50 - $100 $100 - $200 $200 - $300 $300 - $400 $400 - $500 $500 - $1,000 $1,000 + Insurance cost (per yr): < $5,000 $5,000 - $10,000 $10,000 - $20,000 $20,000 - $30,000 $30,000 - $40,000 $40,000 - $50.000 $50,000 + Workers comp cost (per yr): < $5,000 $5,000 - $10,000 $10,000 - $20,000 $20,000 - $30,000 $30,000 - $40,000 $40,000 - $50.000 $50,000 + Insurance renewal date (mo/yr): Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec 2011 2012 2013 2014 2015 PROPERTY COVERAGE/LIMIT AMOUNTS: Building Value(Please note theft exclusion below): < $500,000 $500,000 - $800,000 $800,000 - $1,000,000 $1,000,000 - $2,000,000 $2,000,000 - $3,000,000 $3,000,000 - $5,000,000 $5,000,000 + Content Value (Inc. Equip., Inventory & Property of Others): < $300,000 $300,000 - $500,000 $500,000 - $1,000,000 $1,000,000 - $2,000,000 $2,000,000 - $3,000,000 $3,000,000 - $5,000,000 $5,000,000 + Electronic Data Processing and Equipment: < $5,000 $5,000 - $15,000 $15,000 - $25,000 $25,000 - $35,000 $35,000 - $45,000 $45,000 - $60,000 $60,000 - $80,000 $80,000 - $100,000 $100,000 + Paint inventory & essential equipment: < $5,000 $5,000 - $10,000 $10,000 - $20,000 $20,000 - $50,000 $50,000 - $100,000 $100,000 + Loss of Business Income (Money needed post loss): < $500,000 $500,000 - $800,000 $800,000 - $1,000,000 $1,000,000 - $2,000,000 $2,000,000 - $3,000,000 $3,000,000 - $5,000,000 $5,000,000 + A professional specialist will contact you for authorization to process your confidential application within 72 hours of receipt