Agent Information
Agent Name:
Phone #:	Fax #:
Email Address:

General Information
Name of Insured:
DBA:
Property Location (Street Address):
City:	State:   Zip:
Mailing Address (if different from Property Address):
City:	State:   Zip:

Building/Construction Information
Construction Class:	Please Select One Wood Frame Brick Veneer Joisted Masonry - Tilt-up Joisted Masonry - Reinforced Masonry Joisted Masonry - UnReinforced Masonry Non-Combustible Masonry Non-Combustible Modified Fire Resistive Fire Resistive Modular
Year of Construction:	(yyyy)
Number of Stories:	Select Number of Stories 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20+
Total Square Footage:	sq. ft.
Type of Parking:	Please Select One None Detached* Attached - No Structure Above Habitational over Garage (HOG) Tuckunder - 1 Side Tuckunder - 2 Sides Full Subterranean Partial Subterranean First Floor Parking Soft First Floor Parking    Click Here to see the different parking types
Bolted to Foundation?:	Yes   No

Miscellaneous Information
Details of Building Usage/Occupancy:
Insured's Interest:	Select One Lessor Tenant Owner Occupant
Building Limit:	$  100% Replacement Cost Required - No Blanket Limits
Business Personal Property:	$  100% Replacement Cost Required - No Blanket Limits
Tenant Improvements and Betterments:	$
Deductible Amount:	Select One 2% 5% 10% 15% 20%
Business Interruption Amount:	$
Rental Value/Income:	$
Inspection Contact
Name:
Phone #:

 

Additional Comments

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