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General Commercial questionnaire -New


Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Nature of Business
Optional
Personal Information
First Name
Required
Last Name
Required
Street
Required
City
Required
State
Required
ZIP / Postal Code
Required
Primary Phone Number
Required
E-Mail Address
Required
Effective Date
Optional
/ /
Federal Tax ID
Required
Total Annual Payroll
Required
Total Annual Sales
Required
Year Business Established
Optional
Employees
Total Full Time Employees
Required
Total Part Employees
Optional
Construction Type
Optional
Building Type
Optional
Size of Building in square feet
Required
Year Built
Optional
Number of Stories
Optional
Number of Locations
Required
Property Updates
Year of last Electrical Update
Optional
Year HVAC replaced
Required
Year roof replaced
Required
Year plumbing updated
Optional
Sprinkler system present (Y/N)?
Required
Fire alarm system ( Y/N ) ?
Required
Burglar alarm system (Y/N) ?
Required
Mortgagee and/or Franchiser
Required
Owner/Tenant
Required
Building Coverage limit in dollars.
Required
BPP Limit
Required
Desired policy deductible.
Required
Prior Insurance
Optional
Number of Gas Pumps
Required
If present are gas tanks above or below ground?
Required
If present what is the capacity of the gas tanks?
Optional
Is this there a restaurant on premises?
Required
If the establishment is a restaurant is there cooking, grilling, or frying performed?
Optional
Is there a swimming pool present?
Required
Is liquor served?
Optional
Submission Validation
Required
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Important Notice
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