Commercial Property Coverage Request
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Name (First named Insured & other named insured's)
Street Address:
Apartment Number/ Unit
P.O. Box
City:
State:
California
Zip Code:
Home Telephone:
Work Telephone:
Fax Telephone:
Email Address:
FEIN or Social Security #:
Proposed effective date:
Business entity:
Select one
Individual
Partnership
Corporation
Joint Venture
Subchapters Corporation
Limited Corporation
Not for Profit
Year business start:
Premises Information
Address: Street, City, State, Zip+4
Year Built:
Square footage:
Nature of business/description of operations by premise(s)
Type of business :
Select One
Manufacturing
Non Manufacturing
# of Stories:
Distance to fire hydrant:
Distance to Fire Station:
Burglar alarm type:
Premises fire protection (Sprinklers, standpipes, co2)
****Required information if building is older than 30 years old.*****
Building improvements: (Please list any improvements to wiring, roofing, plumbing, and heating) include year of update.
Roof Type:
(Composition, Tile, Wood, Tin, Metal, Tar & Gravel, etc...)
Construction Type:
( Stucco, Frame, etc....)
Subject of Insurance
Please list desired items to be coverage of policy? ( Example- property, desks, computers, software, etc.)
List items
$ Amount
Please list any additional coverages, options, restrictions, or endorsement.
Please describe the buildings adjacent to your business:
Right Exposure & Distance:
Left Exposure & Distance:
Rear Exposure & Distance:
Additional Interest/Certificate Receipt
Additional Insured |
Loss payee |
Mortgagee |
Lien holder |
Employee as Lessor
Name and Address
Name and Address
Please let us know the best time to contact you
:
IF YOU REQUIRE COMMERICAL GENERAL LIABILITY INSURANCE PLEASE COMPLETE OUR
GENERAL LIABILITY INSURANCE REQUEST FORM.
IMPORTANT NOTE: This form is provided as a convenience to you. We will make a good faith effort to obtain competitive quotes for your review. Depending on the type of business, we may require more information and will contact you if necessary. Your submission of this form DOES NOT guarantee that any binding offers will be forthcoming from insurers we represent.