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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