Property Questions
Age of building / Year Built	Type of building construction	Number of stories	Other occupancies	Square feet you occupy
	--Select One-- Frame Stucco Masonry/Brick Fire Resistive Other
If the building is over 25 years old, please answer the following:
Year Electricity was updated
Is it on circuit breakers?		Yes No
Year Plumbing was updated
Copper or Galvanized plumbing?		Copper Galvanized Other:
Year Building was last re-roofed
Type of roofing material
Type of heating system in the building

Protective Devices
Burglar Alarm	Central Station or local alarm?	Name of alarm company	Is the building sprinklered?	Are there smoke detectors?
Yes No	Central Station Local Alarm		Yes No	Yes No

Liability Questions
Please provide information on previous insurance carrier:
Previous Ins. Carrier	Policy number	Prior premium	Policy renewal date
		$
Please provide information about your business:
Years in business	Projected Gross annual receipts		Projected annual payroll
	$		$
Describe your business, product or service:

Coverage Limits
Building	Contents (equipment, inventory, supplies, etc.)		Deductible	Loss of Income
$	$		--Select One-- $100 $250 $500 $1,000	$
Money and Securities	Glass or signs	General Liability Limit	Non-owned and Hired Automobile Liability	Is liquor liability needed?
$	$	--Select One-- $500,000 $1,000,000 $2,000,000	$	Yes No
If Glass Coverage is needed, please provide dimensions:
Please list other coverages you may need:

Miscellaneous Information
Name of Additional Insured (Landlord or vendor)
Mailing Address
City
State
Zip

Additional Comments

Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough fields above, please enter them here.