First
Name: |
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Last
Name: |
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Business
Name: |
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Address: |
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City: |
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State: |
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Zip
Code: |
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Phone
Number: |
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Fax
Number: |
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eMail
Address: |
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Who
Referred You To Our Site?
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Underwriting Information |
Number of
Owners: |
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Number
of Employees:
(or Enter NONE) |
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Payroll
of Owners: |
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Payroll
of Employees:
(or Enter NONE) |
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Total
Annual Gross Receipts: |
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Total
Annual Sub Costs: |
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Business
License Number: |
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License
Type: |
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Years
of Experience:
(or Enter NONE) |
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How
many years have you operated under your current Business Name? |
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Have
you use any other Business Names during the past 5 years? |
Yes
No
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Is
This Business Open 24 Hours A Day? |
Yes
No
|
Any
Deep Frying (Food)? |
Yes
No
|
Is
There Any Manufacturing, Mixing, Re-Labeling or Repackaging
of Products? |
Yes
No
|
Is
there Filing Of Propane Tanks? |
Yes
No
|
Please
Describe the Nature of Your Business and ANY Unusual Exposures:
|
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Building & Property Information |
Total Square
Footage of the Building Your Business Is In: |
|
Total
Square Footage of Your Business Only:
(or Enter SAME) |
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Square
Footage of the Customer Area Only: |
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How
Many Stories: |
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If
Two Stories, Ground Floor Square Footage: |
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Construction
Type: |
|
Roof
Type: |
|
Roof
Updated? |
Yes
No
|
If
Yes, Year Roof was Updated: |
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Protection
Distance: |
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Is
the Business in a Brush Area? |
Yes
No
|
Is
there Storage more than 1500 Sq Ft? |
Yes
No
|
Are
there Smoke Detectors at this Location? |
Yes
No
|
Fire
Extinguisher? |
Yes
No
|
Deadbolts
on All Doors? |
Yes
No
|
Circuit
Breakers? |
Yes
No
|
Electrical
Updated? |
Yes
No
|
Heating
- Air Conditioning, Thermostatically Controlled?: |
Yes
No
|
Heating
- Air Conditioning, Central? |
Yes
No
|
Plumbing
Updated? |
Yes
No
|
If
Yes, Year Plumbing was Updated: |
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Interior
Automatic Fire Sprinklers: |
|
Theft
Alarm: |
|
Fire
Alarm: |
|
Any
Restaurants in your Building? |
Yes
No
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Any
Restaurants in your Building "Next to Your Business"?
|
Yes
No
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Claims Information |
Losses-Claims
in the last 5 years: |
|
If
yes, Date, Amount Paid and Description of Each Loss-Claim:
|
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Coverage Information |
Current Insurance
Company: |
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How
much are You Paying Now?: |
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Liability
Limit Requested: |
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Building
Limit Requested: |
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Building
Deductible Requested: |
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Business
Personal Property (Contents) Limit Requested: |
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Contents
Deductible Requested: |
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Loss
Of Income Limit Requested: |
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Questions
or Comments
or Additional Coverage you may need: |
|
|