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Quote Application

Business Information

Property Location

Building Overview

Prior Insurance & Claims

Coverages

Business Information

Named Insured

Address Line 1

Address Line 2

City

State

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ZIP

DBA

FEIN #

Phone

Cell Phone

Fax

E-mail

Owned Property Since

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Number Years Experience

Policy Expiration Date

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# Building Locations

Building Location #1

Property

select

Description / Use

Location Address

Type of Construction

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Year Built

select

Total SQ FT

# Units

# Fire Divisions

# Story

# Passenger Elevators

# Freight

# Separate Structures (other than parking)

Describe Other Structures

Resident Manager

YesNo

# Yrs Experience

Property Manager

YesNo

# Yrs Experience

On Site Property Manager / Office

YesNo

Owner Lives On Site

YesNo

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Building Overview

Step /

Building Safety

Circuit Breakers

YesNo

Smoke Detectors

YesNo

Is Building In A Gated Community or Have Security Gates?

If Yes, Describe

YesNo

Is The Building Designed For Its Current Type Of Operations?

YesNo

Was Any Building Converted From A Different Type Of Occupancy?

If Yes, Describe

YesNo

Any Wood Burning Stoves?

YesNo

Any Charcoal Barbecues Used On Wood Decks, Patios Or Balconies?

YesNo

Are All Exterior Doors Equipped With Deadbolt Locks?

YesNo

Is There A Change Locks Procedure?

YesNo

Hard Wired

YesNo

Carbon Monoxide Detectors

YesNo

Fire Extinguishers

If Yes, #

Tagged / Up-to-date

YesNo

Interior Hallways / Stairs?

If Yes, Fire Doors YesNo

Auto-Closing Doors YesNo

YesNo

Does The Building Have Standpipes On Each Floor?

If Yes, # Each floor

If Interior Hallways, Are There Approved And Posted Evacuation Plans?

YesNo

Railings Less Than 4 inches (If over 4″)

If Yes, Willing To Modify YesNo

YesNo

Any Non-Releasable Window Bars?

If Yes, Will They Be Removed YesNo

YesNo

Fire Alarms

YesNo

Central Station / Monitored

YesNo

Any Burglar Alarms or Monitored Security?

If Yes, Describe

YesNo

Building Sprinklers

If Yes, %

Garage Areas

If Yes, %

Building Sprinklers Inspected in Last 5 Years?

If Yes, Date

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YesNo

Building Sprinklers Regularly Monitored / Maintained

If Yes, Describe

YesNo

Building Sprinklers — Is there A Current Sprinkler Certificate?

YesNo

# Pools

If Yes,

# Spas

If Yes,

Pools / Spas Fenced

Fence Over 5ft YesNo

YesNo

Pool / Spa: Is there a self-closing, self-locking gate?

YesNo

Any Diving Board or Slides?

YesNo

Is Depth Of Pool Marked And Pool Rules Posted?

YesNo

Are Safety Rules Posted And Life Saving Apparatus Available?

YesNo

Are All Pools / Spas Equipped With Anti-entrapment Device And/Or System For Drain Cover?

YesNo

Are There Armed Guards On The Premises?

YesNo

Is There a Written Safety Plan?

YesNo

How often is property inspected

If Yes, months

Are There Any Signs Of Pre-Existing Or Water Damage To the Building?

If Yes, Describe

YesNo

Any Roads Maintained or Owned?

If Yes, Describe

YesNo

Any Recreation Rooms?

If Yes, Describe

YesNo

Any Tennis, Racquet, Or Other Courts?

If Yes, Describe

YesNo

Any Playgrounds? If Yes, Describe Type of Surface

If Yes, Describe

YesNo

Any Saunas or Steam Rooms?

If Yes, Describe

YesNo

Any Ponds, Lakes, or Streams?

If Yes, Describe

YesNo

Any Greenbelts or Parks?

If Yes, Describe

YesNo

Does The Property Have Marina Docks Or Lakefront?

If Yes, Describe

YesNo

Is There Any Timeshare Or Short Term Rentals?

If Yes, Describe

YesNo

If Habitational, Are There Any Risks That Are Not Habitational?

If Yes, Describe

YesNo

Employee Training

YesNo

Employee Screening

YesNo

Any Uncompleted Recommendations?

If Yes, Describe

YesNo

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Prior Insurance & Claims

Step /

Prior Insurance Information

Present Insurance Carrier

select

Is Carrier Offering Renewal

YesNo

If No, Why? Explain

Policy Number

Expiration Date

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How Long With This Carrier

select

If Less Than 5 Years, List All Prior Carriers & Policy Numbers On Next Step.

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Claims Information (Last 5 Years)

Are Loss Runs On File?

YesNo

If No, Have They Been Requested?

YesNo

Date Requested

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Any Claim for Sexual Abuse / Molestation?

YesNo

If Yes, Describe

# Claims

Claim #1

Carrier Name

select

Policy Number

Date Of Loss

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Description Of Loss

Amount Paid

Amount Reserved

Claim

select

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Coverages & Annual Premiums

Building Coverage Limits

Blanket Coverage

YesNo

Valuation

select

Business Property Limits

Rental / Income / Fees Limits

General Liability Limits

Umbrella / Excess Liability

YesNo

If Yes, Limits Premium

Property Deductible

Liability Deductible

Annual Premium

Earthquake

YesNo

Premium

Carrier Credits / Discounts

Discounts Requested (%)

Discounts Given (%)

Remarks / Notes

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Business Information

Building Location #1

Building Safety

Building Updates Quick View

House Keeping Quick View

Prior Insurance Information

Claims Information (Last 5 Years)

Claim #1

Coverages & Annual Premiums

Carrier Credits / Discounts

Remarks / Notes

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