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PROPERTY

Location Address*

Street Address Address Line 2 City State ZIP Code

Square Footage

Year Built

Construction Type

# of Stories

Year Updated

Roof Type

Roof Material

Sprinklers - % of Building

Please enter a number from 0 to 100.

Distance from Fire Hydrant (feet)

Please enter a number greater than or equal to 0.

What % of the Building Do You Occupy?

Please enter a number from 0 to 100.

Limit of Insurance for Business Personal Property/Contents

Please enter a number from 0 to 100.

Computer Coverage (Including Mechanical Breakdown)

Desired Limits for Each

Hardware

Software

Tools & Equipment

Desired Limits for Each

Unscheduled Equipment

Scheduled Equipment

For Scheduled Equipment Please Provide Itemized Listing to Include: (Description, Year, Make, Model, Serial Number, Valuation)

Please Indicate Additional Coverage Desired

Limits for Each

Crime Employee Dishonesty

Forgery/Alteration

Money & Securities Inside

Money & Securities Outside

Umbrella Liability Limit

Hired & Non-Owned Auto

Worker's Compensation

Number of Employees*

Please enter a number greater than or equal to 0.

Description of Duties*

Estimated Annual Payroll - Cap Payroll at $36,000 Per Employee Per Policy Term*

Partners, Officers, Relatives To Be INCLUDED or EXCLUDED From Coverage

Name, Title, % of Ownership, Include/Exclude, Duties, Remuneration*

PROPERTY

Computer Coverage (Including Mechanical Breakdown)

Tools & Equipment

Please Indicate Additional Coverage Desired

General Liability

Worker's Compensation

Partners, Officers, Relatives To Be INCLUDED or EXCLUDED From Coverage

Other Documentation Needed

4584 North Rancho Drive | Las Vegas, NV 89130

(702) 646-2082