Your Name (required)

Your Email (required)

Your Corporate Name

Effective Date

Your Business Address

Which coverage would you like?
 Building Coverage Business Personal Property Both

Business Personal Property?(This is the total value of your office contents. i.e. equipment, furniture etc.)
 $75,000 $100,000 $150,000 $200,000 $250,000 $300,000

What type of building is your business located in?
 Private House Commercial Building

What is the Square footage of your office space? (Give an approximate number if you aren't sure.)

What year was the building built? (Give an approximate number if you aren't sure.)

What year was the building improved?(i.e. electric, plumbing, roofing)(Give an approximate number if you aren't sure.)

If you own the building, what is the value? (Give an approximate number if you aren't sure.)

Construction Type?
 Brick Wood Frame Metal Building With steel frame

Do you have an Automatic Sprinkler System?
 Yes No

General Liability? (Protects you from third-party claims and lawsuits)
 $1,000,000/$2,000,000 $2,000,000/$4,000,000

Have you had any claims in the last 5 Years?
 Yes No

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