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800-987-5051

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Applicant Information

Named Insured:

FEIN:

Trade Name (DBA):

Mailing Address:

City

State

Zip

Physical Address:

City

State

Zip

Contact Name:

Title:

Cell Phone:

Email

Year Started:

Hours of Operation:

Gasoline Brand:

No. of Employees:

Full Time

Part Time

Estimated Annual Payroll:

Have there been any losses in the last 5 years?

Yes

No

Current Carrier:

Are you being nonrenewed?

Yes

No

Current Expiration Date:

Exposures

Convenience Store:

Sales

Per Month

Per Year

Gasoline:

Gallons

Per Month

Per Year

LPG:

Sales

Refill

Exchange

Liquor:

Percentage of Store Sales

Per Month

Self Service

Car Wash:

Sales

Per Year

Full Service

Auto Services:

Sales

Per Month

Per Year

Restaurant:

Sales

Per Month

Per Year

Other:

Describe:

Property

Own/Lease:

Construction Type:

Year Built:

Square Footage:

No. of Canopies:

Number of Pumps:

Submit 5-year Loss Runs; Copy of Current Policy; Non-Renewal Notice; Description of Claims

This is mandatory

Drag files here or choose files

CA LICENSE # 0E89987

EXCELSURE INSURANCE SERVICES

18377 Beach Boulevard,

Suite 325,

Huntington Beach, CA 92648

Phone. 800-987-5051

SUBMIT PAYMENT TO EXCELSURE

EXCELSURE INSURANCE SERVICES © 2024

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