1. TYPE OF COVERAGE:

PROPERTY    GENERAL LIABILITY    UMBRELLA

2. CLIENT INFORMATION:


NAME:  DBA:

MAILING ADDRESS:

CITY:  STATE: CA   ZIP CODE:

PHONE:  EMAIL ADDRESS:

3. BUSINESS INFORMATION:

YEARS IN BUSINESS: AT PRESENT LOCATION:

SALES: $     % OF ALCOHOL SALES:

PAYROLL: $

4. TYPE OF ORGANIZATION:

INDIVIDUAL    PARTNERSHIP    CORPORATION

5. LOCATION INFORMATION:

ADDRESS:      CITY:

STATE: CA    ZIP CODE:

INTEREST: Owner Tenant  CONSTRUCTION TYPE: Frame Masonry Metal  #STORIES: 1 2 3 4 5 6 7 +

YEAR BUILT:   TOTAL AREA: Sq.Ft.

6. BURGLAR ALARM:  NO  YES   "IF YES"   LOCAL CENTRAL

FIRE PROTECTION:   NO  YES   EXTINGUISHERS: HOW MANY 1 2 3 4

SPRINKLERS: FULLY  PARTIAL

7. LAST UPDATE:

ELECTRICAL    ROOF    PLUMBING

8. NATURE OF BUSINESS/DESCRIPTION OF OPERATION:

9. DESIRED COVERAGES:

BUILDING $     CONTENTS $

10. LIABILITY LIMITS: $ $1,000,000 $ 500,000 $ 300,000 $ 100,000

11. IS THE BUSINESS PRESENTLY INSURED?   NO   YES

(IF YES, WITH WHOM?)

COMMENTS: