Company Name:

MAILING ADDRESS

Street Address:

Town:

State:

ZIP:

PHYSICAL ADDRESS 

(IF SAME AS MAILING - LEAVE BLANK)

Industry Type:

Retail Service Lessor's Risk (Property Owner) Office Institutional (Church, Civic Organization, School, etc.)

Please provide details for all of your business operations.

Insurance History:

Currently Have Insurance New Purchase/Venture - No Previous Insurance Never Had Insurance Insurance Lapsed

Years in Business:

Less Than One 1-3 Years 3-5 Years Over 5 Years

Property Coverage: (Complete if needed)

* **IF YOU HAVE MORE THAN ONE LOCATION, PLEASE SUBMIT 1 FORM FOR EACH LOCATION; HOWEVER YOU ONLY NEED TO FILL IN THE NAME, PHYSICAL ADDRESS,  AND PROPERTY INFORMATION FOR EACH ADDITIONAL LOCATION***

• If Other, Please Describe:

Fire Hydrants within 1000 Feet:

Yes No  

Fire Station within 5 Miles:

Yes No

Sprinklers:

No Yes  

Central Station Monitored Burglar Alarm:

Yes No  

Central Station Monitored Fire Alarm:

Yes No  

Year of Construction:

Building Construction Type:

Frame Masonary with Wood Roof Masonary with Steel Roof Fire Resistive  

Building Value if Coverage is Desired(Enter $ Amount):

Contents Value if Coverage is Desired(Enter $ Amount):

Deductible:

$250 $500 $1,000 $1,000+

Glass Coverage:

Yes No  

• If Yes, Linear Feet (Enter #):

Sign Value (Enter $ Amount):

Liability Coverage:

Delivery Service:

Yes Not Applicable No

Gross Annual Receipts (Enter $ Amount):

Gross Annual Payroll (Enter $ Amount):

Square Footage of Premises:

Additional Insured(s):

Yes No  

• Number Requested:

General Liability Limit:

$1 Million $500,000 $300,000  

Liquor Liability Limit (If Applicable):

$1 Million $500,000 $300,000  

Umbrella Liability (If Desired):

$1 Million $2 Million $3 Million $4 Million $5 Million $10 Million $20 Million $25 Million

Claims Information:

Any Property Claims within 3 Years:

Yes No  

• If So, Describe (Include Date and Pay Out Amount):

Any Liability Claims within 3 Years:

Yes No  

• If So, Describe (Include Date and Pay Out Amount):

Contact's Name:

Contact's Phone Number (Include Area Code):

Contact's Fax Number (Include Area Code):

Contact's E-Mail Address: