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General Information
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Building/Construction Information
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General Information
First Name
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Last Name
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Business Name
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DBA
Business Address
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Mailing Address
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Phone Number
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Email Address
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General Information
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Building/Construction Information
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Miscellaneous Information
Building/Construction Information
Construction Class
*
Wood Frame/ Stucco
Brick Veneer
Joisted Masonary - Tilt-up
Joisted Masonary - Reinforced Masonary
Joisted Masonary - Unreinforced Masonary
Non-Combustible
Masonry Non-Combustible
Modified Fire Resistive
Fire Resistive
Modular
Other
Year of Construction
Please specify the type of construction
Total Square Footage (sq. ft.)
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Type of Parking
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None
Detached
Attached - No Structure Above
Habitational over Garage (HOG)
Tuckunder - 1 Side
Tuckunder - 2 Sides
Full Subterranean
Partial Subterranean
First Floor Parking
Soft First Floor Parking
Number of Stories
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Bolted To Foundation?
Yes
No
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General Information
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Building/Construction Information
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Miscellaneous Information
Miscellaneous Information
Details of Building Usage/Occupancy
What is your interest?
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Lessor (Building Owner)
Tenant
Owner Occupant
Building Limit (100% Replacement Cost Required - No Blanket Limits)
Business Personal Property (If Applicable)
Tenant Improvements and Betterments
Deductible Amount
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2%
5%
Other
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Business Interruption Amount
Rental Value/Income
Additional Comments
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