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    Commercial Fact Finder

    Agent *

    Requested Effective Date

    Legal entity of insured *

    IndividualPartnershipCorporationLLC

    DBA *

    Agent Phone *

    Agent Fax

    Year business was started *

    Named Insured *

    Address *

    City/State/Zip *

    Federal Tax ID#

    Description of Operations *

    Business Phone *

    Fax Phone

    Insured's Website

    Insured Address

    Insured City/State/Zip

    Insured's Address

    Insured's City/State/Zip

    Insured location is the same as the mailing address? Please provide if differentInsured's location is the same as the mailing address? Please provide if different

    Is the insured operating under another entity or business?

    YesNo

    Additional Insured Locations:#

    Location 1 Address

    Location 2 Address

    Location 3 Address

    Location 1 City/State/Zip

    Location 2 City/State/Zip

    Location 3 City/State/Zip

    Quoting

    BOP/GL/PropertyAutoWCUmbrellaOther

    Any bankruptcies in the past 7 years?

    YesNo

    Any liens on business?

    YesNo

    Has insured been cancelled, declined, or non-renewed by another carrier within the past year?

    YesNo

    Workers Compensation

    Number of Employees

    Full Time

    Part Time

    Payroll Total $

    Experience Modification

    Payroll by classification (Please provide class # and payroll )

    General Liability

    Receipts $

    Any Manufacturing Activities

    Limit of Liability $ (CSL)

    OR Split Liability / $

    Property Damage $

    Gross Sales by Classification

    Operations

    Products

    Additional Endorsements:

    Commercial Auto

    Hired Auto Libility

    YesNo

    Non-owned Liability

    YesNo

    Liability Limit

    UM/UIM Limit: $

    PIP: $

    Physical Damage: Comp Ded. $

    Collision Ded. $

    Additional Endorsements:


    We will need the vehicle schedule that would include serial numbers and cost new

    Commercial Property

    Occupancy Type:

    OwnerTenantLessor

    Age of Construction

    Number of Stories

    Building Square Feet

    Construction:

    FrameJoisted MasonryNon-CombustileMasonry Non-CombustibleModified Fire ResistiveFire Resistive

    Location Sprinklered:

    YesNo

    Safe on Premises:

    YesNo

    Alarms:

    YesNo

    Year of Improvements:

    Wiring

    Plumbing

    Roof

    Heating

    Building Limit: $

    Replacement Cost: $

    Actual Cost Value: $

    Business Personal Limit: $

    Business Income: $

    Coinsurance (%)

    Deductible

    $250$500$1,000$2,500Other

    Other

    Umbrella

    Umbrella

    YesNo

    Limit of Liability

    $1M$2M$3M$4M$5M

    Claims History by Line of

    Additional Information

    Contact Info

    Contact Name *

    Contact Email *

    Contact Phone *

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