Property and Inland Marine Form

Date:

Phone #

Fax #

Business Name:

Contact Name:

Owners Names:

Address (mailing):

City& Zip:

**SS# or Fein#

Web Address/e-mail:

Description of business in detail:

Is business: Corporation Partnership Individual

Number of years in business:

prior experience:

Current Insurance Carrier

Current Premium

Has any business policy been cancelled, or non-renewed in the last three years? Yes No

Any claims in the last three years? Yes No

If yes, please describe:

**Address of each location: (Physical Location)

Must have building info for all property coverage

Location 1

Location 2

Coverage for business property:

Sq. Foot of Building

Age of building

Is the building to be covered?

Yes No

Construction type:

Block Metal

Sprinkler

Yes No

Alarm

Yes No

Central Alarm

Yes No

Any updates and the date:

Roof

Date:

Electical wiring

Date:

Plumbing

Date:

Heating or cooling

Date:

Total Remodel

Date:

Inland Marine coverage:

Description of item

Model

Year

Use of item

$ Value

Do you have unscheduled tools? Yes No If yes, Value needed

Optional Coverages

Money and Securities Limit on premises, off premises

Accounts Receivable Limit

Employee Dishonesty Limit

When Are deposits made? Daily Weekly Monthly

Is money kept in safe? Yes No If no, where is money kept?

Home Owners Association

# of Homes, Condos, Townhouses

# of people on the board

Is there a pool? If yes, how deep is gate self-locking? rules posted?
fenced? how high is the fence? Playground? If yes, what type of equipment?

Restaurant Coverage:

Type of fire suppression system: Ansel Water other : explain other:

Is there a bar? If yes, is it separated from the restaurant? Seating of the bar

Type of Liquor License

Sq. footage open to the public

Is there smoking? how are the ashtrays and contents handled? Are trays emptied in a metal container?

Auto garages

# of bays Number of lifts what kind of lock on the lift