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February 20, 2019
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General Information
Contact Name *
Contact Email *
How did you hear about us? *
Post Card
Website
Referral
Brad Hancock
Scott Kirby
Emory Estes
Susan Elliott
June Landa
Karen Easter
Melissa Cano
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
Association
Church
Corporation
LLC
Municipality
Non-Profit
Partnership
Sole Proprietor
Other (describe)
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
Frame
Brick Veneer
Stucco
Metal
Concrete
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
$250
$500
$1,000
$2,500
$5,000
1%
2%
All Other Perils Deductible
$250
$500
$1,000
$2,500
$5,000
1%
2%
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
Frame
Brick Veneer
Metal
Stucco
Concrete
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
$250
$500
$1,000
$2,500
$5,000
1%
2%
All Other Perils Deductible
$250
$500
$1,000
$2,500
$5,000
1%
2%
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.
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