 |
Insurance Application
| Store Number | |
|---|---|
| Contact | |
| Phone Fax | |
| Address 1 | |
| Address 2 | |
| City | State ZIP |
| Desired Coverage Effective Date | |
|---|---|
| Federal Tax ID # | Years in business |
| Annual Payroll for Employees $ |
|---|
|
| Store Number | |
|---|---|
| Contact | |
| Phone Fax | |
| Address 1 | |
| Address 2 | |
| City | State ZIP |
| Desired Coverage Effective Date | |
|---|---|
| Federal Tax ID # | Years in business |
| Annual Payroll for Employees $ |
|---|
| Building Value | Square Footage | ||
|---|---|---|---|
| Age of Building | Last Update | ||
| Construction Type | # of Stories | ||
| Sprinkler System | Miles from Coast |
What is the value of your equipment and contents:
Gross Receipts:
| Coverages | Current | Desired |
|---|---|---|
| General Liability Limit | ||
| Limit on Autos Covered | ||
| Deductible on Covered Autos | ||
| Umbrella Liability Limit |
| Complete for each auto | ||||||||||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
|
| Describe any losses in the last four years including
date of loss:
|
By submitting your application, we can provide you with a competitive
quote. You are under no obligation to join the program.
Insurance Program Administered by Lockton Risk Services