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NAME/ DBA:   DECISION MAKER: 
PROPERTY LOCATION:
MAILING ADDRESS:
TELEPHONE NO:   FAX NO:    CELL PH NO
YEARS IN BUSINESS:   *IF NEW VENTURE, YEARS EXPERIENCE IN "THIS" BUSINESS: 
PRESENT CARRIER:   PREMIUM:$

OTHER DETAILS:


PROPERTY COVERAGE

BUILDING LIMITS:
CONTENTS LIMITS:
NO. OF FLOORS:   AGE:    CONSTRUCTION: 
ANY LOSSES?:   YES    NO  *IF YES, TYPE & COST:  
TOTAL SQ. FT.:  
  *IF OLDER THAN 25 YEARS WHEN WAS PLUMBING, WIRING, ROOF RENOVATED?: 
  FIRE PROTECTION (EXTINGUISHERS, SMOKE DETECTORS, OR ALARMS)?    YES    NO
  BURGLARY PROTECTION (ALARMS, BARS, ETC.):    YES    NO
  IF APARTMENT OR OFFICE BUILDING, WHAT IS THE OCCUPANCY RATE?:  %
OTHER:

 

GENERAL LIABILITY

LIMITS: $  FLOOR AREA (SQ. FT.):    
ANNUAL PAYROLL: $
TOTAL RECEIPTS: $  NO. OF UNITS:    NO. OF FULL-TIME EMPLOYEES: 
  WHAT % OF WORK IS SUBBED OUT?  %  NEED COMMERCIAL AUTO?:  YES    NO
OTHER:

 

WORKER'S COMPENSATION
EMPLOYEES:  ESTIMATED ANNUAL PAYROLLS:  $
TYPE OF BUSINESS:     OWNER'S PAYROLL:  $
CLASS CODE (S): IS OWNER TO BE COVERED?:    YES    NO
TAX ID:   NEED HIGHER LIMIT WORKER COMP:
OWNERS BD 


  

 

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