Hudson Valley Building Insurance

Commercial Building Insurance Quote Application
Name of Applicant*

PrefixFirst NameMiddle NameLast Name
E-mail of Applicant*
example@example.com
Phone number of Applicant
Format: (000) 000-0000.
Mobile Phone number of Applicant
Format: (000) 000-0000.
Fax Number of Applicant
Format: (000) 000-0000.
Ownership Name (if Corporation please fill out with Corp. name
Location

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County Name?
Year Built?
How Many Floors?
How Many tenants in floor ?
No of Elevators?
Basement?*

YesNo
No of Exits
Total SQ FT?
Owner occupied?
List of Commercial Tenants?
Occupancy Rate
Can you send me the pictures of building?

Cancelof
Type of Construction?
Type of Building?
Updated?

RoofElectricPlumbingHVAC
Year of each update
Sprinklers Installed(100%)? /All Units*

YesNo
Central Fire/ Burglar Alarm?*

YesNo
Are you in city limit?*

YesNo
Annual Rental Income?
Can you send me the pictures or copy of current policy?

Cancelof
Current Insurance Company
Current Building $ Coverage?
Current Liability $ Coverage?
Current Premium $?
Current Insurance Expired date?

MonthDayYear
Fire Station name & How far from (mile?)
Any Optional Coverage Requested Or On Last Policy?
Any Claims in Last 3 yrs?*

YesNo
Claim Date and Year?

MonthDayYear
Have you ordered loss runs from current Insurance Company?*

YesNo
Additional Insured and/Or loss payee?*
Lender Name*
The information provided in this application shall not be shared to anyone else and is kept confidential
Bank (Lender) Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Lender's Email address?
example@example.com
Building Condition?
Should be Empty:

Commercial Building Insurance Quote Application