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Business Information Name Name Of Business Email Address City State Zip Code     Years in Business Policy Period Daytime Phone - - Evening Phone - - Fax - - How would you prefer to be contacted regarding your quote (choose one)? Phone Fax Mail Email If you would prefer to be contacted by phone, please let us know the best time to call am  pm Business Type Individual Corporation Partnership Joint Venture Other Location Address Street   City   State   Zip Code   Interest of premises Owner Owner/Lessor Service Office Habitational Program Retail Wholesale Service Office Habitational Description of Operations Mortgagee Name and Address Limits of Insurance and Optional Coverage Building Value Replacement Cost $  Actual Cash Value $  Construction: Frame Joisted Masonry Masonry: Noncombustible Fire Resistive Sq. foot area of each building Sq. foot area occupied by applicant Year of Construction Number of Stories Business Personal Property Deductible $500 $1000 $2500 $5000 $10000 Exterior Glass Sign Money & Securities $10,000 Inside/$2,000 outside Systems breakdown / boiler & machinery Accounts Receivable Valuable Papers Business Computer: Hardware Software Employee Dishonesty Business Liability $500,000 $1,000,000 Additional insured name & address Non-owned & hired automobile Yes No Annual Sales Annual Payroll 3 Year Prior Carrier Policy # Expiration Date Premium Loss History Date Of Loss Loss Description Amount Remarks