Toll Free
1.877.599.6274
Business / Commercial Property / General Liability
Name Insured
Company
*
Contact Name
*
Address
*
City, State, ZIP
*
Business Phone
*
Email Address
*
FEIN or Social Security #
*
Eff. Date
*
Exp. Date
*
Named Insured is
*
Select One
Individual
Partnership
Corporation
Other
Insured Interest is
*
Select One
Owner Occupant
Lessor
Tenant Only
Years in Business
*
Number of Years at this Location
*
Payroll (excluding drivers, salespeople, and clerical)
*
Square Feet
*
Sales
*
Desired Coverage Limits
Building
*
Protection Class
*
Business Personal Property
*
General Liability
*
Select One
$300,000/$600,000
$500,000/$1,000,000
$1,000,000/$1,000,000
$1,000,000/$2,000,000
$2,000,000/$4,000,000
Construction Type
*
Select One
Frame
JM
NC
MNC
MFR
FR
Year Built
*
Sprinklers
*
Select One
Yes
No
Alarm
*
Select One
Yes
No
If yes to Alarm, what type?
*
