| First and Last Name: |
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| Address: |
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| State: |
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| Zip: |
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| County: |
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| Home Phone: |
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| Work Phone: |
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| Cell Phone: |
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| Fax: |
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| E-Mail: |
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| Household Income: |
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| Own or Rent? |
Own
Rent
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| Time in Residence: |
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| Social Security Number: |
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| Date Of Birth: |
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| Best time to contact: |
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| Comments: |
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| Company: |
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| Description of the business: |
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| Type of entity: |
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| Please indicate the state in which your business is located: |
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| Date of incorporation/registration: |
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| Please indicate your total number of full-time employees: |
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| Please indicate your total number of part-time employees: |
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| Please indicate your total annual revenue: |
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| Do you currently have business insurance: |
Yes
No
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| If insured, select current carrier: |
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| If not listed: please give company name: |
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| How long in years, have you had coverage with this company? |
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| How long in years have you contineously had coverage without A lapse in coverage? |
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| If you do not have coverage, please indicate when you would like a policy to go into effect: |
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| Liability amount: |
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| Deductible: |
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| Additional Coverage Riders : |
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| In
the past 5 years have you reported your losses for the property? |
Yes
No
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| If yes, were those claims: |
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| Business address: |
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| State: |
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| Zip |
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| Do you own or lease the location? |
Lease
Own
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| Year built |
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| Number of stories in the building: |
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| Which floor do you occupy? |
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| Number of sq ft occupied: |
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| Construction type |
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| Does your suite have sprinkers? |
Yes
No
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| Type of parking available: |
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| Are there day care facilities? |
Yes
No
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| Outside cleaning services: |
Yes
No
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| Is
there a pools? |
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| Is the pool fenced? |
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| Does the building have security? |
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| Type of security |
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| Is your office located within 1000 ft of a fire hydrant? |
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| Hours of operation |
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| Do you work weekends? |
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| Please note any schedule personal property items or collectibles for which you need extra coverage. |
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