Commercial Building Insurance Application Form

Commercial Building Insurance Quote Application
Ownership/Corporation Name/Trust
Type of entity
Contact name

PrefixFirst NameLast Name
E-mail Address
example@example.com
Contact Number
Mailing address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Location address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Year Built
Number of buildings
Number of Floors
Number of Units
Any residential tenants? if so, how many?
Number of Elevators
Total Square Feet
Number units owner occupied
Is there a basement?

YesNo
Occupancy Rate (%)
List of Tenants
Type of Construction
Type of Building
Type of Roof
What type of electrical in the building?

100% Circuit BreakersKnob and TubeFusesother
Year Roof Updated
Year Electrical Updated
Year Plumbing Updated
Year Water Heater Replaced
Are any of the electrical panels (Sub panels and Main panels) one of the following: Federal Noark, Federal Pacific - Stab-Lok, Zinc, Magentrip, Sylvania -Zinsco, or GTE Sylvania-Zinsco?

NoYes
Sprinkler Installed(100%)? /All Units

YesNo
Is there a central fire alarm?

YesNo
Is there a central burglar alarm?

YesNo
Annual Rental Income ($)
Please upload the pictures or copy of the current policy.

Cancelof
Current Insurance Company
Current Building Coverage ($)
Current Premium ($)
Current Liability Coverage ($)
Current Business Personal Property coverage
Ex. common area furniture
Current Insurance Expiration Date

MonthDayYear
Fire Station Name
How far from the fire station? (miles)
Any optional coverage must be included?
Any claims in the last 3 years?

YesNo
Claim Date and Year?

MonthDayYear
Claim Date and Year?

MonthDayYear
Claim Date and Year?

MonthDayYear
Upload '3 year loss runs'

Please request loss runs from your current and any previous insurance company in the last three year.
Cancelof
Additional insured and/or loss payee?
Lender Name
Bank (Lender) Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Loan #
How did you hear about us?
Should be Empty:

Commercial Building Insurance Quote Application