| First
Name: |
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| Last
Name: |
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| Business
Name: |
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| Mailing
Address: |
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| Mailing
City: |
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| Mailing
State: |
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| Mailing
Zip Code: |
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| Phone
Number: |
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| Fax
Number: |
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| E-Mail
Address: |
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| Who
Referred You To Our Site?
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PROPERTY ADDRESS (if different)
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Property Address:
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| Property
City: |
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| Property
State: |
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| Property
Zip Code:
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UNDERWRITING INFORMATION
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Please Describe the Exact Nature of Your Business
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| Type
of Ownership: |
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| Number
of Owners: |
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| Number
of Full Time Operators: |
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| Number
of Part Time Operators: |
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| Number
of Stations: |
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| Annual
Payroll of Owners: |
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| Annual
Payroll of Employees: |
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| Total
Annual Gross Receipts: |
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| Salon
Location: |
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| Total
Square Footage of the Building Your Business Is In: |
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| Square
Footage Of Your Business Only: |
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| Business
License Number: |
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| License
Type: |
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| Years
of Experience: |
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| How
Many Years Have You Operated This Business: |
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| How
Many Stories Is The Building: |
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| Construction
Type: |
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| Roof
Type: |
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| Roof
Updated: |
yes
no
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| If
Yes, Estimated Year Roof was Updated: |
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| Protection
Distance: |
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| Is
The Business In A Brush Area? |
yes
no
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| Is
This Business Open 24 Hours A Day? |
yes
no
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| Is
There Storage More Than 1500 Sq Ft? |
yes
no
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| Are
There Smoke Detectors At This Location? |
yes
no
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| Smoke
Alarm: |
yes
no
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| Fire
Extinguisher: |
yes
no
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| Deadbolts
On All Doors? |
yes
no
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| Circuit
Breakers: |
yes
no
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| Electrical
Updated: |
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| Heating
- Air Conditioning, Thermostatically Controlled?: |
yes
no
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| Heating
- Air Conditioning, Central? |
yes
no
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| Plumbing
Updated: |
yes
no
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| If
Yes, Estimated Year Plumbing was Updated: |
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| Interior
Automatic Fire Sprinklers: |
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| Theft
Alarm: |
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| Fire
Alarm:
|
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SALON SERVICES
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Any Deep Frying (Food)?
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yes
no
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| Do
Electrolysis Services? |
yes
no
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| Do
Hair Removal by Electronic Tweezer Services? |
yes
no
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| Do
Chiropody or Podiatry Services? |
yes
no
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| Do
Wart or Mole Removal Services? |
yes
no
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| Do
Reducing, Slendering or Exercising Services? |
yes
no
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| Do
Tanning Services? |
yes
no
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| Do
Skin Treatments or Facial Services? |
yes
no
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| Do
Electric or Steam Baths or Sauna Services? |
yes
no
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| Do
Hair Implants or Transplant Services? |
yes
no
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| Do
Hair Weaving Services? |
yes
no
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| Do
Ear Piercing Services? |
yes
no
|
| Do
Bodywaxing Services? |
yes
no
|
| Do
Bodywrapping Services? |
yes
no
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| Do
Nail Sculpturing Services? |
yes
no
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| Do
Tattoo Services? |
yes
no
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| Do
Permanent Make-up Services? |
yes
no
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| Do
Hair Straightening Services? |
yes
no
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| If
Yes, Chemical Base of the Relaxer: |
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| Is
There Any Manufacturing, Mixing, Re-Labeling or Repackaging of Products?
|
yes
no
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COVERAGE INFORMATION
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Building Coverage:
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| Other
Structures Coverage: |
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| Business
Contents Coverage: |
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| Loss
of Use Coverage: |
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| Liability
Limits Requested: |
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| Policy
Deductible:
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MISC INFORMATION
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Losses-Claims in the last 5 years:
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| If
yes, date, amount paid and description of each loss-claim |
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| Current
Insurance Company: |
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| Expiration
Date: |
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| Current
Premium $: |
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Questions
or Comments
to help the Agent: |
|
Please press the Submit Button ONCE.
Then wait for online confirmation of your request.
Thank you for your interest.
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