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Agent Information
Agent Name
Agent E-Mail
Agent Phone Number
Street Address
City
State
Zip Code
Insured Name
Insured E-Mail
Phone Number
Street Address
City
State
Zip Code
Commercial Property Section
Insured Information
Description of Operations
# of Owner
Annual Payroll for Employees
Annual Cost Of Subcontractors
Annual Gross Receipts
# of Additional Insured
# of Waivers
# of Sq. Ft.
Are Contractors Used?
Yes
No
Are Contractors Insured?
Yes
No
What percentage of Work?
(if over 25% subcontracted work then we will need the contractors supplement application)
General Liability Limits Requested
Property Location
Occupancy
# of Sq. Ft.
Construction
# of Stories
Year Built
Year of Updates for the Following:
Plumbing
Heating
Roof
Wiring
Protective Safeguards:
Central Station Fire Alarm
Central Station Burglar Alarm
Ansul System
Sprinkler System
Building Limit
BPP Limit
BI Limit
Other
Valuation:
ACV
RC
Cause of Loss:
Special
Broad
Basic
Losses
Prior Carrier Info
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