• Proposed Effective Date
• Insured Name
• Number of Full Time Employees
• Number of Part Time Employees
• DBA
• Years in Business
• Address
• Mailing address if different
• Telephone
• Legal Entity
• Nature of Business/Description of Operations

• Building Limit $
• Contents Limit $
• Deductible  

• Occurence/Aggregate
•    Hired and Non-owned Products & Completed Operations Personal & Advertising Injury Medical Expense

• Construction Type
• Year Built
• Last Update - Roof
• Last Update - Electrical
• Number of Stories
• Central Fire Alarm  Yes No
• Central Intrusion Alarm  Yes No
• Fully Sprinklered  Yes No
• Sales/Receipts
• Insured Square Footage
• Leased Square Footeage

• Workers Compensation  Yes No
• Automobile Liability  Yes No

*Need seperate accord application for workers compensation or automobile liability.

Please input loss information for the last 3 full years plus current year

Loss 1

• Date of Loss
• Amount Paid
• Type of Loss (fire/lightning, general liability, vandalism/theft, wind/hail, water, or describe other)

Loss 2

• Date of Loss
• Amount Paid
• Type of Loss (fire/lightning, general liability, vandalism/theft, wind/hail, water, or describe other)

Loss 3

• Date of Loss
• Amount Paid
• Type of Loss (fire/lightning, general liability, vandalism/theft, wind/hail, water, or describe other)

• Additional Interests  Yes No
• Mortgagee  Yes No