| Contact Information |
| First Name
Required
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| Last Name
Required
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| Business Name
Required
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| Website
Optional
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| E-Mail Address
Required
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| Primary Phone Number
Required
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| Business Entity Type
Required
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| Year Business Established
Required
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| F.E.I.N.
Required
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| In the past 3 years, have there been any losses/claims, cancellation or non-renewals with existing insurance carrier?
Required
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| Annual Gross Sales
Required
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| Current Carrier
Optional
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| Premium
Optional
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| Expiration Date
Optional
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| Property Information |
| Street
Required
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| City
Required
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| State
Required
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| ZIP / Postal Code
Required
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| Building Limit
Required
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| Business Personal Property Limit (Replacement Cost)
Required
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| Deductible
Required
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| Location Details |
| Year of Construction
Required
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**If > 30 years old, complete updates below. |
| Date of updates |
| Wiring
Optional
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| Roof
Optional
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| Plumbing
Optional
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| Heat
Optional
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| Are there circuit breakers?
Optional
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| Aluminium wiring
Optional
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| Sprinklered
Optional
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| Number of Stories
Optional
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| Square Footage
Required
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| **If > 10,000 sq feet & fire walls present, what is the area between?
Required
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| Square footage you occupy
Required
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| Construction Type (Select One) |
| FRAME: Exterior walls of wood or other combustible materials, including construction where combustible materials are combined with other materials, such as brick veneer, stone veneer, wood iron clad, or stucco on wood
Optional
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| JOISTED MASONRY : Exterior walls are constructed of masonry materials such as adobe, brick, concrete,gypsum block, hollow concrete block, stone,tile or similar material and where floors and roof are combustible
Optional
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| LIGHT NON-COMB : Exterior walls, floors, and roof are constructed of and supported by metal, gypsum or non combustible material
Optional
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| HEAVY NON-COMB/ FIRE RESIST : Exterior walls are constructed of masonry materials {adobe, brick, concrete, gypsum block, hollow concrete block, stone or tile} or other fire resistive materials
Optional
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| Is there a Loss Payee/Mortgagee (lienholder) for any of this property?
Required
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| If so, do they need to be listed on the policy as a Loss Payee or Additional Insured?
Optional
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| General Liability |
| Typically we offer limits at $1,000,000 per occurrence with a $2,000,000 aggregate. Please advise if different limits are required. |
| Is there a landlord/property owner that needs to see the general liability coverages?
Required
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| If so, do they need to be listed as "Additional Insured" on the policy (for the office space).
Optional
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| Please provide the name of Landlord
Optional
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| Please provide the address of Landlord
Optional
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| Please list # of 1099 subcontractors
Required
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| Annual revenue
Required
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| # of Employees (if more than zero, then annual payroll)
Required
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Submission Validation Required |
Enter the Validation Code from above.
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