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  Your Company Information:
 
Name Of Business:
 
Year In Business:
 
Contact Name:
 
Phone:
 
Fax:
 
Email:
 
Location Address:
 
City:
 
State:
Zip:
     
  Insurance Information (Not Brokerage):    No Prior Coverage  
  Current Carrier:
  Type of Policy:
  Policy Exp. Date:
  Claims in Past 3 Yrs: Yes    No
     
  Property Information:  
 
  Building Interest: Own    Lease
  Construction of Building:
  Square Footage Occupied:
  Automatic Sprinkler System: Yes    No
  Central Station Burglar Alarm: Yes    No
  Business Personal Property value:
  Number of Canopies:
  Number of Pumps:
     
  Description of Operations:  
 
  Hours of Operation:
  Are You a Franchisee: Yes    No
  Any Cooking on Premise incl. Microwave: Yes    No
  Brand of Gasoline:
     
  Breakdown of Annual Sales:  
 
  Mini-Mart:   N/A
  Alcohol:   N/A
  Gasoline:   N/A
  Propane:   N/A
  Auto Repair:   N/A
  Car Wash:   N/A
  Restaurant:   N/A
     
  Workers Compensation Supplemental:  
 
  Federal Tax ID:
  Total # of Employees:
  Total # of Owners/Officers/Executives:
  Estimated Gross Annual Payroll:
     
  How Did You Hear About Us:  
 
  How Did You Hear About Us:

 
 
 
Address: 1041 W. 18th Street, Suite A204, Costa Mesa, CA 92627 Phone: (800) 987-5051
Excelsure

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