Business Entity ---IndividualJoint VenturePartnershipCorporationLLCLLP
Mailing Address if different
Square Footage of Building Occupied
Year building built
Number of Stories
X1 x2 x3 x4
Building Construction Type
Frame Stucko Masonry Fire Resistant
Building Has Automated Ceiling Sprinklers?
Please Describe in Detail the Type of your business
What are some of the types of products sold?
Total Annual Gross Receipts
Years of Experience
Years you have owned this business
Central Station Alarm?
Building Coverage Amount if Owned
Contents coverage amount
Garage Keepers Coverage
Physical Damage (DD)
x 50,000 x 75,000 x 150,000 x 200,000 x 250,000 x 300,000 x 350,000
x 500 x 1,000 x 2,500
Employees tool coverage (DD)?
Do you currently have insurance?
Losses in Last three Years (Please Describe and Loss Amount)