PROPERTY / GENERAL LIABILITY APPLICATION

Business Name:
Mailing Address:
City    State        Zip
County:

PROPOSED EFFECTIVE DATE:
From     To
12:01 A.M. Standard Time at the address of the Applicant
Email Address:
Phone:      Fax:  

Contact Name:      Best Time To Call:  

Number Full-Time Employees     Number Part-Time Employees

Years in Business:    Gross Annual Sales: $       Gross Annual Payroll: $

Describe the Nature of Business:

 CURRENT INSURANCE INFORMATION
 Company Name (not agency):     Policy Expiration Date:      Amount insured for: $
 Years insured:   Premium Amount: $    Term:      If Other:
  If less than 3 years, prior company:

 Prior Losses/Dates (last 3 years):
 Include Description, Date, Amount
 COVERAGE
 Building Limit: $      Contents Replacement Value:
 Liability Limit (Occurrence/Aggregate):       Property Deductible:
 
Type of Coverage: 
 CONSTRUCTION
 Exterior:    Age of building:
 Square footage of your business area?    Square footage of the entire building?
 Roof:     Age of roof:     
 Stories in building:     Updated Heating or  Plumbing? Yes     No

 Within 1000 feet of a fire hydrant?
Within 5 miles of a fire station?
 Central station Burglar Alarm?
Automatic sprinkler system covering 100% of your premises?

Please give any additional comments you feel appropriate for this quotation. If you have additional locations, please enter as much information as you can here.