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About You
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Full Name*
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Business Name*
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Contact Phone Number*
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Fax Number
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Email Address
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Street Address*
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City*
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State*
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Zip*
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Name of Current Insurance Company*
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How Long Have You Been Insured
With That Company?*
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About the Property
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Age Of Building/Year Built:*
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Type Of Building Construction:*
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Number of Stories:*
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Other Occupancies:*
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Square Feet You Occupy:*
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If the building is over 25 years old:
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Year Electricity Was Updated:
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Is It On Circuit Breakers?
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Yes
No
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Year Plumbing Was Updated:
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Copper Or Galvanized Plumbing?
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If other, please specify
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Year Building Was Last Re-Roofed:
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Type Of Roofing Material:
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Type Of Heating System In The Building:
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Burglar Alarm:
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Yes
No
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Central Station Or Local Alarm?
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Central Station
Local Alarm
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Name Of Alarm Company:
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Is The Building Sprinklered?
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Yes
No
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Are There Smoke Detectors?
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Yes
No
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About Your Business:
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Years In Business:*
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Projected Gross Annual Receipts:*
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Projected Annual Payroll:*
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Describe Your Business,
Product Or Service:*
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Coverages:
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Building:*
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Contents (Equipment,
Inventory, Supplies, Etc):*
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Deductible:*
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Loss Of Income:*
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Money And Securities:*
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Glass Or Signs:*
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General Liability Limit:*
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Non-Owned And Hired
Automobile Liability:*
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Is Liquor Liability Needed?*
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Yes
No
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Comments or Questions
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Deliver quote via:*
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Items marked with a * are required
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