Business Entity : *	Individual    Corporation    Association   LLC
	Partnership  Joint Venture    Non-Profit Org   S-Corp
Business Type : *	Manufacturing Office Retail Service Wholesale
Doing Business As:  (Leave Blank if no Business Name)	(Only fill in if they have a Business Name)
First Name of Applicant:	*
Last Name of Applicant:	*
Location Address : (No PO Boxes)	*(No PO Boxes)
City :	*
County :	*
State :	AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA DC WV WI WY *
Zip :	*
Fire Protection Class :	1 2 3 4 5 6 7 8 9 * (Click for Help) 1 - 9
Phone Number :	* ex. 716-837-8804
Web Address :
Describe Business :	*

REQUIRED RATING INFORMATION

Years of Experience :	*
Years at Location :	*
Is Insured Buisness located in an Enclosed Mall :	Yes No *
Is Insured Buisness closed more than 60 consecutive days each year:	Yes No *
Is applicant a member of a Franchise group :	Yes No * If Yes Name of Franchise
Percent of Building that is Vacant :	%*
Are there Apartments in the Building :	Yes No *
Construction :	Joisted Masonry Frame Non-Combustible
	Masonry N/C Fire Resistive*
Building Condition :	Excellent Average Poor Very Poor *
Quality of Construction :	Average Economy Superior *
Total Square Footage of Building :	*
Square Footage occupied by insured :	*
Number of Floors :	*
Other occupancies in Building :	*
Is Basement :	Finished Unfinished No Basement
(Florida only) Wind pool :	Yes No *
Miles to nearest body of water:	*
Is the building 100% Sprinklered? :	Yes No *
Type of Burglar alarm :	Local Central Station None Other *
Age of Building in Years :	*    If over 25 years enter the following
When was Electric Updated :	(mm/dd/yyyy)
When was Heating Updated :	(mm/dd/yyyy)
When was Plumbing Updated :	(mm/dd/yyyy)
When was Roofing Update :	(mm/dd/yyyy)
Number of owners :	*
Owners Payroll :	*
For the following 3 items, enter Employees only, do not include Owners or Clerical.
Full Time Employees :	*
Part Time Employees :	*
Employee Payroll :	*
Annual Gross Receipts :	*
Currently have coverage? :	Yes No *
Was there past coverage? :	Yes No *
The following 6 items are required if they had prior coverage or currently have coverage.
Enter name of most recent carrier :	Policy #
Is or was policy being cancelled or non-renewed?	Yes No(Not Applicable in MO)
If yes, please explain:
Most recent Policy Premium :
Loss History: (Date of loss, Brief Desc. and Amount Paid)
If none enter NONE :

COVERAGE INFORMATION

Liability Limits 1: ($)	300/600 500/1,000 1,000/2,000 2,000/4,000 *
Liability Limits 2: (optional): ($)	300/600 500/1,000 1,000/2,000 2,000/4,000
Building Limit :
Valuation :	ACTUAL CASH VALUE REPLACEMENT COST
Contents Limit :
Property Deductible :	$250 $500 $1,000 $2,500 $5,000

OPTIONAL COVERAGE

Computer Equipment Hardware Limit :
Computer Equipment Software Limit :
Equipment Breakdown to be excluded:	Yes No
External Surge Protectors :	Yes No
Business Income :	Yes No
Employee Dishonesty Limit :	$10,000 $20,000 $30,000 $40,000 $50,000 $75,000 $100,000 $125,000 None
# of Employees :
Names and Addresses :
Fire Legal Limit :
Food Spoilage Limit :
Glass (need both) :
Linear Feet :
Square Feet :
Glass Dollar Value :
Hired and Non-owned Auto Liability Limit :
Sign Type :	Inside Outside
Sign Construction Type : Sign Limit : Garage Keepers Limit : (Minimum $25,000)
Garage Keepers Deductible:
Number of Gas Pumps :
Is Business open 24hrs?	Yes No

Additional Insured(s): How Many?:
What is their interest:

Comments: