COMMERCIAL FIRE APPLICATION

Applicant's Name:
Mailing Address:
City    State        Zip
Phone:      Fax:

PROPOSED EFFECTIVE DATE:
From     To
12:01 A.M. Standard Time at the address of the Applicant
Email Address:
PLEASE ANSWER ALL QUESTIONS - IF THEY DO NOT APPLY, INDICATE 'NOT APPLICABLE'

1. Applicant is:   Individual Corporation Partnership Joint Venture
                              Other (Specify)

 


2. Number of years in business:

3. Describe all business operations conducted by applicant:

 


4. Premises information:
Loc. No.
Street Address
City
County
State
Zip Code
Interest
Part Occupied

5. Previous carrier and loss information (last three years):     Check if no losses last three years.
Year
Company
Policy #
Premium
Date of Loss
Pd Losses
Res Losses
Description
Any other insurance with this company or being submitted?      Yes    No 
Please list name[s] and/or policy number[s]):
 Any policy or coverage declined, cancelled or nonrenewed during the prior three years? Yes    No
Why?

6. Premises Information:
Prem-
ises
No.
Exposure
Amount Requested
Coins. %
ACV/Repl. Cost
Cause of Loss
Deductible
Special Conditions
Building
$
Building
$
Building
$
Contents
$
Contents
$
Contents
$
Business
Interruption
$
Business
Interruption
$
Business
Interruption
$
Other
$
Other
$
Other
$
Bldg.
No.
 		 Mortgagee or loss payee:
Additional coverages, restrictions and endorsement information:
 Other carriers participating on risk:
1.      %
2.      %

Construction type:

Protection class:

Number of stories:

Total square foot area:

Total number of units:

Sprinklered? Yes    No

Operable smoke detectors? Yes    No

Year built:

Building remodeling (include year):

 Wiring?
Yes    No
Year:
 Heating?
Yes    No
Year:
 Plumbing?
Yes    No
Year:
 Roof?
Yes    No
Year:
Burglar alarm type:
Local   Central Station
Fire alarm type:
Local   Central Station

Application Completed By:     Date: