CLIENT INFORMATION Business Name Entity --Select--INDVCORPLLCPRTNOTHER Building Construction --Select--Wood FrameBrick or ConcreteFire ResistiveOther Is your property? --Select--Owner OccupiedTenant OccupiedVacantUnder course of construction Type of Business : Years In Business : Years Experience : Property Address Email Address Website : Type of Business : --Select--OfficeLessor’s RiskWholesalerManufacturerRetailerServiceRestaurantApartment Building Description Of Operations: INSURANCE & RATING INFORMATION Current Carrier: Exp Date Policy # Current Premium Any losses? --Select--YesNo Loss Description Status --Select--OpenClosed Do You Have Employees? --Select--YESNO If yes, How Many? Estimate Estimated Gross Sales: $ Liquor Sales (Beer, Wine, or hard liquor) --Select--YesNo Has the building been renovated? YesNo Plumbing Year Renovated Electrical Year Renovated Roof Year Renovated Heating Year Renovated Building Structure: --Select--FrameJoisted MasMason-Non-CombFire ResistiveUnknown Fire Sprinkler --Select--YESNO Central Alarm --Select--YESNO Total Sq. Feet Public SQ. Feet: Building Updated --Select--YesNo Number of Stories Number of Buildings Year Built Hours of Operation General Liability Limits: --Select--$500k/$1mm$1mm/$2mm$2mm/$4mm Building Limits Contents Restaurant Equipment/Tenant Improvement value Delivery or Catering? --Select--YesNo Any Entertainment, dance floor, and happy hours? --Select--YesNo Other Quote Options Professional LiabilityUmbrellaGarageAutoErrors & Omission The above information is true to the best of my knowledge. I authorize Insure Pal Insurance Services the use of the above information for the purpose of obtaining a quotation for insurance. I also understand by submitting this information does not mean that I have purchased an insurance policy. This information is used only to provide a quote.