Commercial Building Insurance Application Form

Commercial Building Insurance Quote Application
Name of Applicant
PrefixFirst 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
County Name
Built Date
MonthDayYear
Date
Number of Floors
Number of Tenants in the Floor
Number of Elevators
Number of Exit Stairs
Total Square Feet
Number of Owners Occupied
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
Clear
Should be Empty: