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 Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough fields above, please enter them here.

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