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Company Name
DBA
Entity Type
Individual
Partnership
Corporation
LLC
Other
Contact Name
Phone
Email
Mailing Address
City
State
WA
Zip
Current Ins Company
Policy Number
Effective Date
Losses in the last four Years
Payroll
Number of Employees
Annual Gross Receipts
Type of Product Sold
Property Coverage
Location 1
Address
City
State
WA
Zip
Construction Type
Frame
Steel
Masonry
Other
Year Built
Square Footage
Number of Stories
Building Limit
Contents Limit
Computer Limit
Owner
Tenant
% Occupied
%
Sprinklered
Yes
No
Year Updated
Electrical
Roofing
Plumbing
Heating
Location 2
Address
City
State
WA
Zip
Construction Type
Frame
Steel
Masonry
Other
Year Built
Square Footage
Number of Stories
Building Limit
Contents Limit
Computer Limit
Owner
Tenant
% Occupied
%
Sprinklered
Yes
No
Year Updated
Electrical
Roofing
Plumbing
Heating
Crime Coverage
Money & Securities
$5,000
$10,000
$25,000
$50,000
Employee Dishonesty
$5,000
$10,000
$25,000
$50,000
Motor Truck Cargo
No. of Vehicles Hauling Cargo
Average Value of Cargo per Vehicle
Maximum Loss Limit
Liability Coverage
Liability Limit
$300,000 / $600,000
$500,000 / $1,000,000
$1,000,000 / $2,000,000
$2,000,000 / $4,000,000
Liability Umbrella
$1,000,000
$2,000,000
$3,000,000
$4,000,000
$5,000,000
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