General Information
Name *
Address
Address2
City
 State
 Zip Code (zip + 4)
Work Phone (include area code)
 Fax Number (include area code)
E-mail Address *
Rating Information
Occupant of Building
Owner    Tenant   
Usage of Building
Corporation    Individual    Partnership   
Age of Building
 Square Feet
Construction of Building
 Number of Stories
Roof Type
 Roof Age (years)
Protection of Building
Alarm
Central    Local   
# Fire Extinguishers
 Ansul System
Yes    No   
# Smoke Detectors
Fire District
Current Insurance Carrier
Any Losses
Insurance Limits and Coverages (whole numbers)
Limits
Building $
 Business Personal Property $
Business Interruption (loss of income) $
Coverages
Special X-theft    Theft    Broad    Basic   
Effective Date of Coverage
 Deductible $
Comments/Questions

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