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Applicant Information

Name *
Address 1 *
Address 2
City *
State *
Zip *
Daytime Phone
Evening Phone
Cell Phone
Email *
* Indicates required information

Property Coverage Information

Building Value:
Year Built:
Square Footage:
ContentslBusiness Personal Property Value:
Building located in
Fire Department Name:
Distance to Fire Hydrant:
Distance to Fire Station:
Protection Class:
Bldg. Construction:
Age of Roof:
Upgrades to Plumbing/Date:
Upgrades to Wiring/Date:
HVAC Upgrades/Date:
Other occupancies of building:
Percentage of Building occupied by owner:
Percentage of Building occupied by tenants:
Any Loss Payees/Mortgagees:
Is property within 1000 feet ofcommercially navigable body of water or located in a flood zone?
Additional Coverages
Business Income:
Computer/electronic Equipment:
Loss of Rents:
Equipment Breakdown/Steam Boiler:
Equipment Floater:
Crime/Employee Dishonesty:
Any property losses in the last 4 years?
If any, please explain: