Name:        

Address:    

City:            

Zip Code:   

DBA:           

Phone/Fax/Email?                     

Type of Business                       

Years in Business/Experience 

Gross Sales (Receipts):           

Type of Ownership:                     Individual Corporation Partnership Jiont Venture Other

Own or Rent:                                Own Rent

Stories:                                       

Square Feet:                              

Type of Construction:                 Joisted Masonry Fire Resistive Other

Sprinkler System:                       Yes No

Alarm:                                          UL Approved Central Station Line Security

Is Building Free Standing?        Yes No

Any special license/training?    

Current Carrier:                          

Expiration Date:                         

Any Losses/Claims                    
If so, please explain:                   

Type of Insurance Needed:        

Property Information:

Year Constructed:        Owned/Leased:     Structure:     Area:
UPDATES:  Wiring:     Heating:     Plumbing:     Roof:
No. of Employees:       Est. Annual Payroll:     Est. Annual Receipts:

Coverage Required:

Building:         Contents:         Loss of Earnings:
Sign:               Glass:               Pump/Canopy:    

Workers Compensation needed (Limits):

No. of Additional Insured:         Waivers of Subrogation:

Commercial General Liability:

General Aggregate:         2,000,000 1,000,000 500,000 300,000 100,000
Product Aggregate:         2,000,000 1,000,000 500,000 300,000 100,000
Personal & Adv. Injury:    2,000,000 1,000,000 500,000 300,000 100,000
Each Occurrence:            2,000,000 1,000,000 500,000 300,000 100,000
Fire Damage:                   100,000 50,000
Medical Expense:            10,000 5,000 2,000 1,000
Wind Deductible:             20% 10% 5% 3%

How can we reach you?

Send proposal via: Fax Email Mail

**Please note additional underwriting may be required.**