June 24, 2017

Commercial Property Quote

General Information
Contact Name *
Contact Email *
How did you hear about us? *

Business Name *
Mailing Address *
City *
State *
Zip *
County
Business Phone
Cell Phone
Fax
Website
Preferred Method of Contact? Business Phone  Cell Phone  Email  Fax
Current Insurance Company
Insurance Company Name
Policy Expiration Date
Policy Number
Business Information
FEIN #
Business Type
How long in Business? (yrs)
How many locations?
Please give a brief description of your business operations
Property/Premises Information - Location 1
Location 1
Property Address (If different from mailing address)
City
State
Zip
County
Occupancy Status Owner Occupied  Tenant Occupied  Vacant
Year Built
Construction Type
Type of Roof
% Occupied
Central Station Alarm Yes  No
Sprinklered Yes  No
Stories
# Basements
Total building sq. Footage
Sq footage you occupy
Improvements - Location 1
If any improvements or updates been done to the following - what year were they done?
  Wiring Roof Plumbing Heating & A/C
Location 1
Coverage Information - Location 1
Location 1
Building Value
Contents Value
Business Income
Extra Expense
Electronic Data Processing Equipment (EDP)
Equipment Breakdown
Outdoor Signs
Fence
Other - Please Specify
Wind & Hail Deductible
All Other Perils Deductible
Valuation Replacement Cost  Actual Cash Value
Is there a loss payee or mortgagee on this property? Yes  No
If yes to above - please provide name, address and loan number for each loss payee and/or mortgagee.
Describe any claims in the past 3 years
Property/Premises Information - Location 2
Location 2
Address
City
State
Zip
County
Occupancy Status Owner  Tenant
Year Built
Construction Type
Type of Roof
Age of Roof
% Occupied
Central Station Alarm Yes  No
Sprinklered Yes  No
Stories
# of Basements
Total Building Sq Footage
Sq Footage You Occupy
Improvements - Location 2
If any improvements or updates been done to the following - what year were they done?
  Wiring Roof Plumbing Heating & A/C
Location 2
Coverage Information - Location 2
Location 2
Contents Value
Business Income
Extra Expense
Electronic Data Processing Equipment (EDP)
Equipment Breakdown
Outdoor Signs
Fence
Other - Please Specify
Wind & Hail Deductible
All Other Perils Deductible
Valuation Replacement Cost  Actual Cash Value
Is there a loss payee or mortgagee on this property? Yes  No
If yes to above - please provide name, address and loan number for each loss payee and or/mortgagee.
Describe any claims in the past 3 years
Other Information
1a. Is the applicant a subsidiary of another entity? Yes  No
1b. Does the applicant have any subsidiaries? Yes  No
2. Is a formal safety plan in operation? Yes  No
3. Any exposure to flammables, explosives, chemicals? Yes  No
4. Any other insurance applied for with this company? Yes  No
5. Any policy or coverage declined, cancelled or non-renewed during the prior three years for any premises or operation? Yes  No
6. Any past losses or claims relating to sexual abuse or molestation allegations, discrimination or negligent hiring? Yes  No
7. During the last five years, has any applicant been indicted for or convicted of any degree of crime of fraud, bribery, arson or any other arson-related crime in connection with this or any other property? Yes  No
8. Any uncorrected fire and/or safety code violations? Yes  No
9. Has applicant had a foreclosure, repossession, bankruptcy or filed for bankruptcy in the last 5 years? Yes  No
10. Has applicant had a judgement or lien during the last 5 years? Yes  No
11. Has business been placed in a trust? Yes  No
12. Any foreign operations, foreign products dist distributed in the USA, or US products sold/distributed in foreign countries? Yes  No
13. Does applicant have other business ventures for which coverage is not requested? Yes  No

Comments
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Disclaimer Notice - The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.