Name of Applicant:

First Last

Website Address:

Location Address:

Proposed Policy Term:

From Last

Applicant’s Business:

Number of Years in Business:

Have you declared bankruptcy or been in receivership within the past five years?

Yes

No

GENERAL INFORMATION

Complete type of work performed:

Indicate the percentage of principal work performed

Dry Cleaning

%

Laundry

%

Fur Storage

%

Appliance Repair

%

Computer Repair

%

Electronic Repair

%

Television Repair

%

What is the average:

Service charge per order:

$

Number of days required to service:

Value per order:

$

Number of working days:

Indicate the age, type of construction and protection class of the premises:

LIMITS OF INSURANCE AND DEDUCTIBLE

Property In Transit

$

Property In Storage At Your Premises

$

All Covered Property In Any One Occurrence

$

Deductibles

$

List previous insurance carrier(s) for the last three years:

List the last three-year losses:

List any additional information attached with the application:

Prior Policy

Prior Policy Date

_______ to ________

Carrier Name

Coverage Type: Liab/PHD/MTC

POLICY #

# of Units Insured

Any loses within the past 5 years?

If YES please upload on the related documents attaching box below.

Amount Paid

Upload Your Current Insurance Policy or Related Documents

Drop files here or

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