General Information
Name of Insured:
Address:
City:	State:   Zip:
Business Phone:	Fax Number:
Email Address:
Location Address  (type "same" if same as above):
City:	State:   Zip:

 

Property Questions
Age of building /Year Built:	Type of building construction:	Number of stories:	Other occupancies:	Square feet you occupy:
	--Select One-- FrameStuccoMasonry/Brick Fire ResistiveOther			sq. ft.
If the building is over 25 years old, please answer the following:
Year Electricity was updated: Is it on circuit breakers?:		Yes   No
Year Plumbing was updated: Copper or Galvanized plumbing?:		Copper   Galvanized   Other:
Year Building was last re-roofed: Type of roofing material:
Type of heating system in the building:

 

Protective Devices
Burglar Alarm:	Central Station or local alarm?:	Name of alarm company:	Is the building sprinklered?:	Are there smoke detectors?:
Y   N	Central Station  Local Alarm		Y   N	Y   N

 

Liability Questions
Please provide information on previous insurance carrier:
Previous Ins. Carrier:	Policy number:	Prior premium:	Policy renewal date:
		$
Please provide information about your business:
Years in business:	Projected Gross annual receipts:		Projected annual payroll:
	$		$
Describe your business, product or service:

 

Coverage Limits
Building:	Contents (equipment, inventory, supplies, etc.):		Deductible:	Loss of Income:
$	$		--Select One-- $100$250$500 $1,000	$
Money and Securities:	Glass or signs:	General Liability Limit:	Non-owned and Hired Automobile Liability:	Is liquor liability needed?
$	$	--Select One-- $500,000$1,000,000 $2,000,000	$	Yes   No
If Glass Coverage is needed, please provide dimensions:
Please list other coverages you may need:

 

Miscellaneous Information
Name of Additional Insured (Landlord or vendor):
Mailing Address:
City:	State:   Zip:

 

Additional Comments

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