Company Name:
Contact Person:
Phone Number:
Fax Number:
Email Address:
Address:
City:
State:
Zip Code:
Current Insurance Carrier:
Current Expiration Date:
Current Annual Premium:
Estimated Sales:
What is rental percentage?:
Years in Business:
How many losses in the past 3 yrs?:

Building/Contents Information

Year Built:
Building Value (if insured by you):
Contents Value (Avg):
Contents Value (Max):
Deductible:

Ownership:	Tenant Owner
Construction:	Frame Brick Cement/Steel
Type:	Free Standing Strip Mall Shopping Center
Sprinklers:	Yes No
Burgler Alarm:	Yes No