| First Name: |
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| Last Name: |
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| Business Name: |
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| Mailing Address: |
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| Mailing City: |
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| Mailing State: |
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| Mailing Zip Code: |
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| Phone Number: |
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| Fax Number: |
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| E-Mail Address: |
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| How did you find our site? |
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UNDERWRITING INFORMATION |
| Property Address: |
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| Property City: |
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| Property State: |
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| Property Zip Code: |
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| Property County: |
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| Please Describe the Nature of Your Business |
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| Number of Owners: |
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| Number of Employees: |
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| Payroll of Employees: |
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| Total Annual Gross Receipts: |
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| Total Square Footage of the Building Your Business Is In: |
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| Square Footage Of Your Business Only: |
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| Current Insurance Company: |
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| Business License Number: |
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| Years of Experience: |
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| How Many Years Have You Operated This Business: |
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| How Many Stories: |
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| Construction Type: |
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| Roof Type: |
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| Roof Updated: |
yes
no
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| If Yes, Year Roof was Updated: |
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| Protection Distance: |
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| Is This Business Open 24 Hours A Day? |
yes
no
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| Is There Any Manufacturing, Mixing, Re-Labeling or Repackaging of Products? |
yes
no
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| Is there Filing Of Propane Tanks? |
yes
no
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| Are There Smoke Detectors At This Location? |
yes
no
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| Smoke Alarm: |
yes
no
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| Fire Extinguisher: |
yes
no
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| Deadbolts On All Doors? |
yes
no
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| Circuit Breakers: |
yes
no
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| Electrical Updated: |
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| Heating - Air Conditioning, Thermostatically Controlled?: |
yes
no
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| Heating - Air Conditioning, Central? |
yes
no
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| Plumbing Updated: |
yes
no
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| If Yes, Year Plumbing was Updated: |
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| Interior Automatic Fire Sprinklers: |
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| Theft Alarm: |
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| Fire Alarm: |
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| Losses-Claims in the last 5 years: |
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| If yes, date, amount paid and description of each loss-claim |
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COVERAGE INFORMATION |
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Building Coverage: |
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| Other Structures Coverage: |
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| Business Contents Coverage: |
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| Loss of Income Coverage: |
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| Liability Limits Requested: |
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| Policy Deductible: |
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Questions or Comments
to help the Agent: |
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