CORPORATE INFORMATION
Legal Entity That Owns Building:
Mailing Address of Corp:
City
State
Zip Code
Web Site (if available):
Number of Buildings:

LOCATION/S - (If more than five (5) locations contact us directly)
LOCATION ADDRESS / DEVELOPMENT NAME	SQ. FT.	# UNITS	STORIES

LIST RETAIL/COMMERCIAL TENANTS (if any)

Include Sq Ft and Type of Business . . . 1. ABC Company, 2,500 Sq Ft, Clothing

GENERAL PROPERTY INFORMATION
Year of Construction
Construction Type	***SELECT*** Frame Masonry Veneer Masonry Superior Other (Complete Below)
Other Construction Type
Roof Type	***SELECT*** Composite Material Metal Tile Slate Woodshake Other (Complete Below)
Other Roof Type
Foundation Type	***SELECT*** Crawl Space Piers / Pilings / Stilts Slab on Grade Unfinished Basement Walkout Basement Wood Foundation Basement Other (Complete Below)
Other Foundation Type
Central Heating & Air Conditioning?	YES      NO
Stairwells Inside or Outside Building?	INSIDE OUTSIDE
If Inside	OPEN   CLOSED
If Basement Exists - Square Footage
Bsmnt Occupied?	YES      NO
If Bsmnt Occup - 2 Means of Egress?	YES      NO
# of Elevators	NONE
# of Vacant Units
Garage Type	***SELECT*** Outdoor - Assigned Outdoor - Not Assigned Indoor Garage
Sq. Ft. Parking Area / Garage
Are There Circuit Breakers?	YES      NO
Copper Wires?	YES      NO
Heating System Type	***SELECT*** None Heat Pump Electric Gas Oil
If Oil, Tanks Above or Below Ground	ABOVE      BELOW
Cooling System Type	***SELECT*** None Central Air Evaporative Cooler Window Units
Is the Plumbing Copper?	YES      NO
BUILDING UPDATES ROOF (Updated) ELECTRIC (Updated) HEATING (Updated) PLUMBING (Updated) Yes No Yes No Yes No Yes No (If yes, year) (If yes, year) (If yes, year) (If yes, year)

BASIC FIRE SAFETY PROTECTION INFORMATION
Distance from Fire Protection (Hydrant)	***SELECT*** Less Than 1000 Ft. Over 1000 Ft.
Distance from Fire Station	***SELECT*** Less Than 5 Miles More Than 5 Miles More Than 10 Miles
Is Your Area A "Brush" Area?	YES NO
Is There a Standpipe?	YES NO
Is There Emergency Lighting?	YES NO
Are Exit Signs Illuminated?	YES NO
Smoke Detectors At This Location?	YES NO
Smoke Alarm At Location?	YES No
Fire Extinguishers?	YES NO
Interior Automatic Fire Sprinklers?	PARTIAL FULL NONE
Fire Alarm	***SELECT*** Local Central Station None
Theft Alarm	***SELECT*** Local Central Station None
What Is The Fire District?

POOL INFORMATION
Is There a Pool?	YES NO
Is Pool Fenced?	YES NO
Is There A Diving Board?	YES NO
Is There A Slide?	YES NO
Life Guard On Duty?	YES NO

COVERAGE REQUEST
Building Amount
Loss of Rent
DEDUCTIBLE	***SELECT*** $500 $1,000 $2,500 $5,000 $10,000 $15,000 $20,000 $25,000 $50,000
General Liability	***SELECT*** $1,000,000 $2,000,000
Losses-Claims in the Last 5 Years?	YES No
If Losses and/or Claims List - Date, Amount Paid and Description of Each Loss

ADDITIONAL COVERAGE REQUEST
Umbrella	Boiler & Machinery
Workers Compensation	Directors & Officers
Business Auto	Flood

CURRENT COVERAGE INFORMATION
Current Insurance Carrier
Current Expiration Date
Current Premium

CONTACT INFORMATION

First Name: Last Name: *Email: Phone:                        Fax:    Questions/Comments When Do You Need Quote? 24 Hrs 48 Hrs 5 Days 10 Days Other How Did You Hear About Us? Internet Print Publication Radio Friend Other