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Policy
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Contact Information
Building
Policy
Business Information
Todays Date
Full Business Name
Contact Person Full Name
Years in Business
EIN#
Business Phone #
Business Website
Email Address
Requested Effective Date
Exact Nature of Business
Legal Entity
Individual
LLC
Corporation
Partnership
Mailing address
Location Address (if different from above)
Building
Requesting Building limit? (if you own the building) $___________
Construction Type
Number of Buildings Owned by the customer
Square footage of building
Year Built
If building is older than 20 years, please indicate the year each of the following was updated. Roof, Plumbing, Electrical, Heating/HVAC
Does the building have a sprinkler system
Yes
No
Contents Limits (business personal Property)
Annual Gross sales / receipts.
Annual Payroll
Policy
Requested Deductible
$250
$500
$1000
Above $1000
Current Carrier? Optional Coverage(list those of interest)
Current Premium? Loss History (include all losses in the last 3 years, include details, amount paid and if claim is open or closed.
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1559 Lilburn Stone Mountain RD
Suite C
Stone Mountain GA 30087
info@georgiapremier.com
(404) 537-5100
Fax 770-270-5526
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