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GENERAL INFORMATION


1. First Name:   Last Name:
Name of Legal Entity, if other
2. Phone:
3. Email:
4. Business Name:
5. Mailing Address:

City:

   Phone:

State:

  Zip Code:

6. Ownership type:
7. Years in Business: years
8. Currently insured?
9. If yes, Number of years continuously insured: years
10. Name of Current Insurance Company:
10a. Policy No:
11. Losses-claims in the last 5 years:
12. If any Losses, provide date, amount paid and reserves, description, and steps taken to avoid future losses:
13. Has your insurance ever been canceled or non-renewed?
14. If yes for what reason?

15. Nature of Business/Description of Operations by Premises(s), Special Conditions or Circumstances:
16. Gross annual sales or receipts:
17. Number of owners or officers: 18. Annual payroll for all owners or officers:
19. Number of full time employees: 20. Annual payroll for all full time employees:
21. Number of part time employees: 22. Annual payroll for all part time employees:

BUSINESS LOCATION(S) and PROPERTY COVERAGE INFO.

Number of business locations:

LOCATION #1

23. Address:

City:

State:

  Zip Code:
24. Location is used for: (Factory, Warehouse, Office, etc.)
25. Total Area: sq/feet
26. Customer area: sq/feet
27. Parking area: sq/feet
28. Common Parking?
29. Year of Construction:
30. Building Construction Type:
31. If over 30 years old, was the following updated?  If so when?
      Wiring:   Plumbing:   Roof:
  Heating:
32. Is there a Burglar Alarm? 

33. If Yes, Select the Type:

34. Is there a Fire Alarm? 

35. If Yes, Select the Type:

36. Does the building bave sprinklers?

Property Coverage Info. For Location #1


37. Building Coverage Amount: (If you own the building)

38. Deductible:

39. Personal Property Coverage Amount:

40. Deductible:

41. Monthly Business Income Interruption Coverage Required: (includes continuing expenses and net income)
42. Exterior Glass coverage amount:
43. Total size of all exterior glass: sq/feet
44. Exterior Sign coverage amount:
45. Other property coverage(s) required:

If there are no other location(s) go to question # 46

LOCATION #2

23a. Address:

City:

State:

  Zip Code:
24a. Location is used for: (Factory, Warehouse, Office, etc.)
25a. Total Area: sq/feet
26a. Customer area: sq/feet
27a. Parking area: sq/feet
28a. Common Parking?
29a. Year of Construction:
30a. Building Construction Type:
31a. If over 30 years old, was the following updated?  If so when?
      Wiring:   Plumbing:   Roof:   Heating:
32a. Is there a Burglar Alarm? 

33a. If Yes, Select the Type:

34a. Is there a Fire Alarm? 

35a. If Yes, Select the Type:

36a. Does the building bave sprinklers?

Property Coverage Info. For Location #2


37a. Building Coverage Amount: (If you own the building)

38a. Deductible:

39a. Personal Property Coverage Amount:

40a. Deductible:

41a. Monthly Business Income Interruption Coverage Required: (includes continuing expenses and net income)
42a. Exterior Glass coverage amount:
43a. Total size of all exterior glass: sq/feet
44a. Exterior Sign coverage amount:
45a. Other property coverage(s) required:

LOCATION #3

23b. Address:

City:

State:

  Zip Code:
24b. Location is used for: (Factory, Warehouse, Office, etc.)
25b. Total Area: sq/feet
26b. Customer area: sq/feet
27b. Parking area: sq/feet
28b. Common Parking?
29b. Year of Construction:
30b. Building Construction Type:
31b. If over 30 years old, was the following updated?  If so when?
      Wiring:   Plumbing:   Roof:   Heating:
32b. Is there a Burglar Alarm? 

33b. If Yes, Select the Type:

34b. Is there a Fire Alarm? 

35b. If Yes, Select the Type:

36b. Does the building bave sprinklers?

Property Coverage Info. For Location #3


37b. Building Coverage Amount: (If you own the building)

38b. Deductible:

39b. Personal Property Coverage Amount:

40b. Deductible:

41b. Monthly Business Income Interruption Coverage Required: (includes continuing expenses and net income)
42b. Exterior Glass coverage amount:
43b. Total size of all exterior glass: sq/feet
44b. Exterior Sign coverage amount:
45b. Other property coverage(s) required:

46. Additional Location Information:

LIABILITY and OTHER COVERAGE INFO.

47. Liability coverage Limit required:
48. Deductible:
49. Number of additional Insureds:
50. Your business relationship with each additional insured: (Landlord, Job Owner, Contractor, etc.)
51. Other required coverage: (please provide coverage type and amount required) 


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LICENSE #:  0787078

Phone: (800) 316-3002
Fax:    (818) 500-1855

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