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Owner Information:

Owner's Name 

Mailing Address 

City  State   Zip   -

Telephone Fax E-mail

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Company Information:

Type of Business 

Description of Operations:

Legal Entity:     Individual      Partnership     Corporation

DBA 

Location Address 

Mailing Address  

City    State    Zip -

Telephone Fax E-mail

Annual Sales

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Covered Property Information:

Building age    Sq. Footage       Own    Rent   Lease 

Type of building (office, industrial, apartment, etc.)

Construction type (wood frame, masonry, brick, steel, etc.)

Number and type of occupants in building

Alarm/Security System (please detail)

Building improvements and dates:

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Insurance Information

Current Insurance Provider

How long with present provider   Expiration date  

Types of Policies with Company

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Coverages to Quote:

Building Amount $  Contents  $

Liability Amount $  Deductible $

Other

Give a brief description of any losses in the past five years: