Commercial Building Insurance Application Form

Commercial Building Insurance Quote Application
Name of Applicant

First NameLast Name
E-mail Address of Applicant
example@example.com
Contact Number of Applicant
Ownership/Corporation Name
Location

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Built Date

MonthDayYear
Date
Number of Floors
Number of Tenants
Number of Elevators
FEIN#
Total Square Feet
Number of Owners Occupied Units
Is there a basement?

YesNo
Occupancy Rate (%)
List of Tenants
Please upload the pictures of the building.

Cancelof
Type of Construction
Type of Building
Are the followings updated?

RoofElectricPlumbingHVAC
Updated Year
Sprinkler Installed(100%)? /All Units

YesNo
Is there a central fire/burglar alarm?

YesNo
Are you in the city limit?

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 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
Can you get claim report from insurance company?

YesNo
Additional insured and/or loss payee?
Lender Name
Bank (Lender) Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Lender's Email Address
example@example.com
Building Condition

1

2

3

4

5

6

7

8

9

10

1 is Worst, 10 is Best
Submit Date

MonthDayYear
Date
Hour MinutesAM/PM Option
Signature

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Commercial Building Insurance Quote Application