Property Supplement

Personal Information
Name of Facility Optional
Street Required Input Required
City Required Input Required
State Required Input Required	select AL AK AZ AR CA CO CT DE FL GA HI ID IA IL IN KS KY LA ME MD MA MI MN MS MO MT NC ND NE NV NH NJ NM NY OH OK OR PA PR RI SC SD TN TX UT VT VA WA DC WV WI WY AB BC MB NB NL NS NT NU ON PE QC SK YT
ZIP / Postal Code Required Input Required Please enter a valid Postal code.
First Name Required Input Required
Last Name Required Input Required
Primary Phone Number Required Input Required Please enter a valid phone number
Fax Optional
E-Mail Address Required You must provide an e-mail address. A valid e-mail address is required.
Types of coverage looking for (need gross sales broken down by each activity) Optional	Liability Property Excess ECT. Hold down the Ctrl Key to make multiple selections.
Facility Activities (need values of all prop to be insured) Optional	Go-Kart Laser Tag Inflatables Bowling Mini-Golf Batting Cages Paintball Arcade ECT. Hold down the Ctrl Key to make multiple selections.
Expiration date of current policy Optional
Current Insurance Company Optional
Current Premium Optional
Years In Business Optional	select 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50
Gross Sales Optional
Property Info
Building Value Optional
Contents Value Optional
Is building owned or rented? Optional	Owned Rented
Any other occupancies in building Optional	Yes No
Is building sprinklered? Optional	Yes No
Year Built Optional
Construction Type Optional	select Frame Concrete Block Steel Other
Updates Optional	Roof Wiring Plumbing Heating
Alarmed Optional	Burglared Fire
Nearest Fire Hydrant (FT) Optional
Distance to Fire Station (Miles) Optional
Roof Type Optional
Square Footage Optional
Enter Validation Code Required

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