| Business Name: |
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| Contact Name: |
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| Address: |
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| Address Line 2: |
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| City: |
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| Zip Code: |
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| Phone: |
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| Fax: |
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| E-Mail Address: |
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| FEIN or SSN: |
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| Date Business Started: |
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| License Number: |
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| Years of Experience: |
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| Number of
Owners/Officers: |
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| Entity Type: |
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| Do You Have Equipment
Coverage Now? |
Yes No |
| If Yes, Current Carrier: |
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| Policy Expiration Date: |
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| Any Claims in Past 3
Years: |
Yes No |
| If Yes, Please Describe: |
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| Total Value of
Unscheduled Equipment/Small Tools: |
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| Deducible: |
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| Include Theft Coverage: |
Yes No |
| Scheduled
Equipment:
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| Deductible: |
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| Include Theft Coverage: |
Yes No |
| All Equipment Stored at
Main Premises: |
Yes No |
| If No, Please explain
where: |
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| Burglar Alarm: |
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| Fire Alarm: |
> |
| Additional
Remarks: Please
include a detailed description of your business operations. A brief description may
slow down the quoting process and require additional input from you.
Please note that any information that
has not been requested on this application, but is material to the operations of your
business, should be detailed in the additional remarks section of this form. Leaving
out any material information may be considered a misrepresentation.
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