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:

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

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: FULLYPARTIAL

7) LAST UPDATE: ELECTRICALROOFPLUMBING

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?  NOYES 

(IF YES, WITH WHOM?)