Policy and Claims
PLEASE COMPLETE ALL THE ITEMS BELOW FOR YOUR PREVIOUS POLICY INFORMATION:
Gen. Liability Insurance Company:
Policy Date:
Limits:
General Liability Premium:
Sales:
Deductible:
Property Insurance Company:
Policy Date:
Limits:
Property Liability Premium:
Contents:
Bldg. Value: $
Property off premise:
Bus. Income:
Stored Equipment Address:
City:
State:
Zip code:
Construction of building:
Fire Resistive
Mas. Non/comb
Joisted Masonry
Frame
Semi
Other
If other, please describe:
Sprinklered?
Yes
No
Burglar Alarm?
Yes
No
Cen. Station
Local
Age of Building:
Date wiring last updated
Date heating last updated:
Date roofing last updated
Date plumbing last updated:
Would you like to add Auto Coverage?
Automobile Insurance Company:
Policy Date:
Limits:
Automobile Liability Premium:
Travel radius:
No. trucks:
No. Private passengers:
No. trailers:
No. vans:
Would you like to add Umbrella Coverage Coverage?
Umbrella Insurance Company:
Policy Date:
Limits:
Umbrella Liability Premium:
Have you had any claims within the last five years?
How many claims in the past three years?
Please Indicate the year, type, quantity, and amount incurred in the last five years:
Year of claims:
None
2010
2009
2008
2007
Claim Type:
None
Liability
Auto
Property
No. of claims:
Total Amount:
Please Indicate the year, type, quantity, and amount incurred in the last five years:
Year of claims:
None
2010
2009
2008
2007
Claim Type:
None
Liability
Auto
Property
No. of claims:
Total Amount:
Please Indicate the year, type, quantity, and amount incurred in the last five years:
Year of claims:
None
2010
2009
2008
2007
Claim Type:
None
Liability
Auto
Property
No. of claims:
Total Amount:
Please Indicate the year, type, quantity, and amount incurred in the last five years:
Year of claims:
None
2010
2009
2008
2007
Claim Type:
None
Liability
Auto
Property
No. of claims:
Total Amount:
Please Indicate the year, type, quantity, and amount incurred in the last five years:
Year of claims:
None
2010
2009
2008
2007
Claim Type:
None
Liability
Auto
Property
No. of claims:
Total Amount:
Please Indicate the year, type, quantity, and amount incurred in the last five years:
Year of claims:
None
2010
2009
2008
2007
Claim Type:
None
Liability
Auto
Property
No. of claims:
Total Amount:
Please Indicate the year, type, quantity, and amount incurred in the last five years:
Year of claims:
None
2010
2009
2008
2007
Claim Type:
None
Liability
Auto
Property
No. of claims:
Total Amount:
Please Indicate the year, type, quantity, and amount incurred in the last five years:
Year of claims:
None
2010
2009
2008
2007
Claim Type:
None
Liability
Auto
Property
No. of claims:
Total Amount:
Please Indicate the year, type, quantity, and amount incurred in the last five years:
Year of claims:
None
2010
2009
2008
2007
Claim Type:
None
Liability
Auto
Property
No. of claims:
Total Amount:
Please Indicate the year, type, quantity, and amount incurred in the last five years:
Year of claims:
None
2010
2009
2008
2007
Claim Type:
None
Liability
Auto
Property
No. of claims:
Total Amount:
Please Indicate the year, type, quantity, and amount incurred in the last five years:
Year of claims:
None
2010
2009
2008
2007
Claim Type:
None
Liability
Auto
Property
No. of claims:
Total Amount:
Please Indicate the year, type, quantity, and amount incurred in the last five years:
Year of claims:
None
2010
2009
2008
2007
Claim Type:
None
Liability
Auto
Property
No. of claims:
Total Amount:
Please Indicate the year, type, quantity, and amount incurred in the last five years:
Year of claims:
None
2010
2009
2008
2007
Claim Type:
None
Liability
Auto
Property
No. of claims:
Total Amount:
Please Indicate the year, type, quantity, and amount incurred in the last five years:
Year of claims:
None
2010
2009
2008
2007
Claim Type:
None
Liability
Auto
Property
No. of claims:
Total Amount:
Please Indicate the year, type, quantity, and amount incurred in the last five years:
Year of claims:
None
2010
2009
2008
2007
Claim Type:
None
Liability
Auto
Property
No. of claims:
Total Amount: