Texian Insurance: Quotes: Fire

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COMMERCIAL FIRE QUOTE

Applicant's Name:
Mailing Address:
City State Zip
Phone: Fax:

PROPOSED EFFECTIVE DATE:
From To

Email:

PLEASE ANSWER ALL QUESTIONS - IF THEY DO NOT APPLY, INDICATE 'NOT APPLICABLE'

1. Applicant is: Individual Corporation Partnership Joint Venture

Other (Specify)

2. Number of years in business:

3. Describe all business operations conducted by applicant:

5. Previous carrier and loss information (last three years): Check if no losses last three years.
Year	Company	Policy #	Premium	Date of Loss	Pd Losses	Res Losses	Description





Any other insurance with this company or being submitted? Yes No Please list name[s] and/or policy number[s]):				Any policy or coverage declined, cancelled or nonrenewed during the prior three years? Yes No Why?

6. Premises Information:
Prem- ises No.	Exposure	Amount Requested	Coins. %	ACV/Repl. Cost	Cause of Loss	Deductible	Special Conditions
	Building	$
	Building	$
	Building	$
	Contents	$
	Contents	$
	Contents	$
	Business Interruption	$
	Business Interruption	$
	Business Interruption	$
	Other	$
	Other	$
	Other	$
Bldg. No.	Mortgagee or loss payee:
Bldg. No.	Additional coverages, restrictions and endorsement information:			Other carriers participating on risk: 1. % 2. %