| PART
1 |
| Agency's E-mail Address :
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| Submitting Agency :
Fax
No : |
| Contact Person :
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Office Number :
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| Named Insured :
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| Address of Bldg #1 :
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| City:
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State
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| County:
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Zip:
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| Building is used for :
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| If office, what type business :
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| Age of Bldg :
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| Construction Type : |
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| If older than15 Yrs-when updated
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| Roof :
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Electrical :
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| Plumbing :
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Construction :
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| Square Footage:
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| PART
2 |
| Please check all that
apply |
smoke alarms
fire extinguishers |
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burglar bars
inside sprinkler system, |
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Monitored fire/burglar alarms |
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completely fenced |
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Other : |
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| How many feet to the nearest
fire hydrant?
ft |
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| How many miles to the nearest
fire department?
miles |
| If Restaurant,
confirm that a working automatic fire extinguishing
system (Ansul System) is over all cooking equipment
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Serves Alcohol?
Yes
No |
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| If Apartments, Dwellings,
or Condos, the “Habitational Questionnaire”
must be attached along with this sheet |
| #Buildings : |
Total # Units :
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#Ft Apart : |
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| If Convenience / Grocery
Store, |
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do they have a gas station?
Yes
No |
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do they have a car wash?
Yes
No |
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| If Auto Repair, |
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do they do spray painting?
Yes
No |
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has U.L. approved booth?
Yes
No |
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| If Motel / Hotel, |
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how many units?
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restaurant?
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swimming pool?
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Monitored Alarm :
Yes
No |
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Include Theft :
Yes
No |
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| (Note: Theft cannot be quoted
unless there is a central station monitored alarm system
on the premises) |
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| PART
3 |
| #1 BUILDING AMOUNT
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| #1 CONTENTS AMOUNT
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| Sign$ |
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| Canopy $ |
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| Loss of Income $ |
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| Gas Pump$
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| Fence$ |
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| # Of Years Owned / Leased
(circle one) |
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| # Of Years Experience
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| COVERAGES : |
BASIC RCV
BROAD
ACV
SPECIAL |
THEFT (Monitored alarm system
required for theft coverage. Only available with Broad
or Special Form)
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| PART
4 |
| How many years prior insurance
on this property?
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| Any Losses Or Claims In The
Past 3 Years? |
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YES
NO
N/A |
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| If YES, Please Give Details
As Well As Amount(s) Paid Out For Each |
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