| Name of applicant: |
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| Address of applicant: |
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| Location of risk: |
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| Name of business: |
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| Type of business: |
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| Previous carriers and policies for last three years: |
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| Losses past three years: |
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| Policy effective date: |
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| Insured value: |
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| Property deductible: |
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| Limit of liability: |
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| Business classification: |
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| Payment installment plan: |
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| Name and address of mortgage/loss payee: |
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| Name and address of lessor as additional insured: |
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| Hired and non-owned auto coverage? |
Yes
No |
| Year of construction: |
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| Year of update if over 25 years: |
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| Type of construction: |
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| Number of floors: |
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| Number of subterranean floors: |
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| Total building area: |
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| Area occupied by insured: |
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| Percent of area sprinklered: |
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| Other occupants of the building: |
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| Position of occupant relative to insured location: |
Left
Right
Below
Above |
| Number of full-time employees: |
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| Number of part-time employees: |
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| Number of fire extinguishers: |
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| Type of alarm system: |
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| Barred windows and/or doors? |
Yes
No |
| Surge protection: |
Yes
No |
| Dead-bolt locks: |
Yes
No |
| Year insured started business: |
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| Years of experience in business: |
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| Years insured at this location: |
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| Has insured ever filed for bankruptcy? |
Yes
No |
| Sell or serve alcohol? |
Yes
No |
| Annual gross sales: |
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| Annual liquor sales (if any): |
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| Percentage of sales from: |
Repair
Rental
Installation |
| Any sale of used items: |
Yes
No |
| Percentage of delivery: |
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| Does store remain open after 10:00pm? |
Yes
No |
| If yes, give store hours: |
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| Is operation franchised? |
Yes
No |
| Are foreign products directly imported and sold? |
Yes
No |
| If yes, give details: |
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