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License# 0L09546
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Step One:
Complete Form
Step Two:
Review and Submit
Step Three:
Finish
Welcome to
Commerical EZ-App
from A&M.
For fast service on your commercial accounts complete the form below and hit the "Step Two" button. Your submission will be electronically delivered to the next available Commercial Lines Underwriter.
Coverage Requested:
Package
Monoline Liability
Monoline Property
Applicant Name:
Applicant Website Address:
Location address:
City:
State:
Zip Code:
Applicant's Primary Telephone #
Description of Risk:
Prior Losses?
Yes
No
If yes, include 5 years hard copy loss runs with submission.
Has applicant had any policies or coverage’s cancelled or non-renewed in the past three years?
Yes
No
N/A
Has applicant had prior Bankruptcy in the past 7 years?
Yes
No
N/A
Have any crimes occurred or been attempted on the premises within the last 3 years?
Yes
No
N/A
Expiring Carrier:
Willing to Renew?:
Yes
No
N/A
Renewal Quote:
$
If no, why?:
Target Premium:
$
General Liability
Property
Limits Requested:
$
Payroll:
$
Number of Employees?:
Receipts:
$
Square Footage:
If Apt., # of Units:
Years in Business:
Does the applicant lease Employees to or from other Employers?
Yes
No
N/A
Building:
$
Contents:
$
Loss of Income:
$
Protection Class:
Construction Type:
Square Feet:
Sprinkler?:
Yes
No
N/A
Central Alarm?:
Yes
No
N/A
Year Built:
Is Building 100% on Circuit Breakers?:
Yes
No
If over 20 years old, provide building updates:
Building Updates / (Year)
Wiring (Yr):
Roof (Yr):
Heating/Air (Yr):
Plumbing (Yr):
What is the quality of the housekeeping?
Does the applicant have emergency lighting?
Yes
No
Is the Applicant:
(a) An owner of any other properties or business operations under this legal entity?
(b) Related to another entity through common ownership?
C) Subsidiary of another entity?
If yes to any of the above please explain.
Comments & other Material Information:
Agency Name
:
Contact Person
:
Phone Number:
Fax Number:
E-mail Address:
(You will get a summary page to review before submitting)