First Name:

Last Name:

Business Name:

Mailing Address:

Mailing City:

Mailing State:

Mailing Zip Code:

Phone Number:

Fax Number:

E-Mail Address:



Property Address:


Property City:

Property State:


Property Zip Code:

Property County:

Please Describe the Nature of Your Business

Number of Owners:

Number of Employees:

Payroll of Owners:

Payroll of Employees:

Total Annual Gross Receipts:

Total Square Footage of the Building Your Business Is In:

Square Footage Of Your Business Only:

Current Insurance Company:

Business License Number:

License Type:

Years of Experience:

How Many Years Have You Operated This Business:

How Many Stories:

If Two Stories, Ground Floor Square Footage:  

Total Square Footage of Your Dwelling:  

Construction Type:


Roof Type:


Roof Updated:

yes no 

If Yes, Year Roof was Updated:

Protection Distance:

Is The Business In A Brush Area?

yes no 

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 

Is There Storage More Than 1500 Sq Ft?

yes no 

If An Office Risk, Is E With 1 Million Admitted Coverage Carried?

yes no 

Are There Smoke Detectors At This Location?

yes no 

Smoke Alarm:


Fire Extinguisher:


Deadbolts On All Doors?


Circuit Breakers:

yes no

Electrical Updated:

Heating - Air Conditioning, Thermostatically Controlled?:


Heating - Air Conditioning, Central?

yes no 

Plumbing Updated:


If Yes, Year Plumbing was Updated:

Interior Automatic Fire Sprinklers: 

Theft Alarm:

Fire Alarm:

Losses-Claims in the last 5 years: 


If yes, date, amount paid and description of each loss-claim



Building Coverage:


Other Structures Coverage:

Business Contents Coverage:

Loss of Use Coverage:

Liability Limits Requested:

Policy Deductible:

Questions or Comments
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