FAST AND EASY COMMERCIAL PROPERTY INSURANCE PROPOSAL FOR BUSY PEOPLE

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FIRST NAMEFirst Name

LAST NAME

Dateof appointment

Mailing Address

Unit #your full name

Cityyour city

STATE

CA

ZIPZIP

PHONECELL PHONE#

Emaila valid email

Email again for Accuracya valid email

Business Entitypick one!

Building OwnershipIndividualPartnershipCorporationLLCOther

Currently Insured ?

YesNo

Current Insurance Company name ?your full name

What is your Occupation? (Also list your spouses occupation if married.)

Building Information

Building Address

Cityyour city

STATE

CA

ZIPZIP

Countyyour county

Property Type

Building Occupancy TypeShopping CenterOffice BuildingIndustrial ParkPrivate WarehouseOffice CondominiumHotel / Motel

Year Built

Square Foot Est.

Fully Built

Property Fully Built ?YesNo

If Not Fully Built... Mth / Yr to be completed and details?your full name

Foundation

Foundation Type ?SlabCrawlspaceBasementOther

Parking

Parking ?UndergroundParking LotParking StructureCarportNone

Construction

Construction Type ?FrameBrick/VeneerStoneOther

Roof Type

Roof Type ?ShingleWood ShakeTar/GravelRockSpanish TileMetalOther

Stories

# of Stories ?1 Story1.5 Stories2 Stories3 Stories4 Stories5+ Stories

Baths

# Baths?01 1.5 22.5 344.555.566.577.58910+

Plumbing Type ?pick one!

Plumbing Type ?CopperGalvanizedMixedOther

Heat Type

Select HeatingGasElectricCoalWood BurningOther

Circuit Breakers ?

Circuit Breakers ?Circuit BreakersFuses

Fire Department name

Plumbing Updated?

YesNo

Year & Type of updates?your full name

Claim 3 years?

YesNo

Describe all claims & amounts last 3 years?

Jacuzzi ?

YesNo

Pool ?

YesNo

PLEASE DESCRIBE IN DETAIL HERE ANY SPECIAL FEATURES, ADDITIONS, OR MODIFICATIONS TO THE BUILDING. If none then type "NONE"more details

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Coverage Information

Building Coverage?

Contents Coverageyour full name

Deductiblepick one!

Deductible5001,0002,5005,00010,000

Liability Limitspick one!

Liability Limits1,000,0002,000,0003,000,0005,000,00010,000,000

DESCRIBE ANY SPECIAL COVERAGE REQUESTS SUCH AS HIGH LIABILITY LIMITS, HIGHER BUILDING COVERAGE, etc. LIST THEM HERE. If there is no additional coverage requests or exposures type "NONE"more details

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