Organic Trade Association
Insurance Preliminary Information Sheet

To apply for Insurance, complete this form and press the Submit Button. The fields with red labels are required. The contents of this form will be emailed to Contact at DRIB, and you will receive a confirmation email. The fields with red labels are required.

Name of Business:
Mailing Address:
Contact Person:
Phone:
Fax:
Email:
Website:

Describe your business & products -- please include any insurance issues that concern you:

# of Years in this business:
# of Locations:

What states do you operate in?  

Insurance Values:

Are buildings owned? 
YES NO
Total Building Values – All locations:
Total Contents Values – All locations:
# of Vehicles to be insured:
Any claims issues?
Annual Payroll:
# of Employees:
Sales Projection:
Domestic:
International:
Do you import any products/components?
 YES NO
If yes, what %    
What industry do you sell to?