Name of Your Company

Contact

Mailing Address

Property Address
(if different than mailing address)

FEIN # (9 numbers)

Website address:

Phone Number

What is your business entity

Nature of Business:
Please explain your type of business

Brief description of your business:

When does your policy Expire

Who is the present carrier?

Have you had any losses in the past 3 Years?

Type Of Loss

Amount of Loss

Date Of Loss

Others. Please specify

What is your estimated annual sales?

How many Employees do you have?

What is your estimated annual payroll?

Estimate Annual Liquor sales if any?
Only applicable for Liquore stores, Grocery Stores and Restaurants

Business personal Property

Separate Structure

Loss of Income

Business personal Property of others

Building Ordinance or Law

Electronic Data Processing

Equipment Breakdown

Cargo Or Transportation

Extended Replacement cost

Please let us know about your property

Building Structure

Year Built

Total Building Square feet

The Building Square feet you are occupying

Do you Own the Building

Tenant Occupied

Number of stories

Number of units

Do you have a swimming pool?

Number of swimming pools?

Is it fenced and locked?

Has the building been renovated

Building upgrades and year

Please show the items below were replaced and when

Electrical

Plumbing

Heating

Roof

What was updated?

--Select--

Cloudy

Partly Cloudy

Sunny

When was the update?

--Select--

Cloudy

Partly Cloudy

Sunny

Do you carry worker's compensation?

Do you carry Group Health Insurance?

Is Building Sprinklered?

Do you have an Alarm?

Plumbing

Electrical

Roof

Heating

What percentage of total building is vacant?

Liability Limit Occurrence / Aggregate

Product and completed operation

Umbrella Limit
Would you like to add umbrella coverage?

Commercial General Liability
The first limit is Occurrence and the 2nd limit is aggregate (Maximum limit per year)

Liquor Liability

Deductible

Building Limit:
SCost Per Square Foot (X) Total Square Footage of The Buildingub label

Business Personal Property:
How much it would cost to replace all your fixtures equipment stocks, etc?

Loss of Income and Extra Expenses:
Annual Loss of Income which includes temporary cost of location and operation

Non Owned Auto

Hired Auto

Optional Coverages

Professional Liability E&O

Director and officers Liability

Employment Practice Liability Insurance

Cyber Liability

Frequently Selected Coverage Options
Please select all options you would like to have (Click all that apply)

Building Ordinance or Law

Backup of Sewers & Drains

Computer Fraud (Data Breach)

Earthquake

Earthquake Sprinkler Leakage

Transportation/Cargo

Garagekeepers

Employment Practice Liability (EPLI)

Commercial Vehicle

Personal Property of Others

Bailee (customer's goods in your care custody and control)

Equipment Breakdown

Account Receivable / Valuable Paper

Professional Liability

Liquor Liability

Non-Owned, Hired Auto

Directories and Offices

Other