Commercial Package
Policy
Name of Contact:
DBA:
City:
 Zip:
Email:
 Nature of business:
Estimated
annual payroll:
Years at
current location:
Central station
alarm system:
Fire resistive:
 Sprinkler:
Year built:
Brick:
 Attached:
No. of stories:
Frame:
 Detached:
Total area sq. footage:
Public area sq. footage:
Type of business adjacent - left of you:
 Right of you:
General liability:
 Professional liability
Content:
Loss of income:
 Product liability:
* if landlord required to be certificate
holder or additional insured.
Currently insurance
company:
Insurance loss/claim
in the past 3 years:
Owner name:
Bus. address:
Proposed
effective date:
Coverage limits:
What is it?
Bus. phone:
Location
information -
check all that
apply:
Landlord name
& address: