June 24, 2017

Lessors Risk 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?
Property/Premises Information - Location 1
Location 1
Property Address (If different from mailing address)
City
State
Zip
County
Year Built
Construction Type
Type of Roof
Central Station Alarm Yes  No
Sprinklered Yes  No
Stories
# Basements
Total building sq. Footage
% Occupied
Name of each tenant and type of business
Improvements - Location 1
If any improvements or updates been done to the following - what year were they done?
  Wiring Roofing Plumbing Heating & A/C
Location 1
Coverage Information - Location 1
Location 1
Building Value
Contents Value
Business Income / Loss of Rents
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
Year Built
Construction Type
Type of Roof
Central Station Alarm Yes  No
Sprinklered Yes  No
Stories
# of Basements
Total Building Sq Footage
% Occupied
Name of each tenant and type of business
Improvements - Location 2
If any improvements or updates been done to the following - what year were they done?
  Wiring Roofing Plumbing Heating & A/C
Location 2
Coverage Information - Location 2
Location 2
Building Value
Contents Value
Business Income / Loss of Rents
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
Is the applicant a subsidiary of another entity? Yes  No
Does the applicant have any subsidiaries? Yes  No
Is a formal safety plan in operation? Yes  No
Any exposure to flammables, explosives, chemicals? Yes  No
Any policy or coverage declined, cancelled or non-renewed during the prior three years for any premises or operation? Yes  No
Any past losses or claims relating to sexual abuse or molestation allegations, discrimination or negligent hiring? Yes  No
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
Any uncorrected fire and/or safety code violations? Yes  No
Has applicant had a foreclosure, repossession, bankruptcy or filed for bankruptcy in the last 5 years? Yes  No
Has applicant had a judgement or lien during the last 5 years? Yes  No
Has business been placed in a trust? Yes  No
Does applicant have other business ventures for which coverage is not requested? Yes  No
Comments
* = Required Field
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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