Your Name

Phone

Alternate Phone

Fax

E-mail

Business Name

Mailing Address
     
Retail Location Address
     
Leasing Agent Name

Leasing Agent Phone Number

General Liability Limits Required - Retail Location

What Is The Retail Location Building Constructed Of?

What Year Was The Retail Location Building Built?

Square Footage Of Retail Location Your Store Occupies

Does The Retail Location Building Have A Sprinkler System?
Yes  No
Does The Retail Location Building Have An Alarm System?
Yes  No
Value/Amount Of Merchandise & Inventory

Value/Amount Of Business & Personal Property (cash drawers, computers, etc.)

Estimated Annual Sales

Estimated Annual Payroll (for workers comp)

Prior Or Current Insurance Carrier

If You Have A Lease On The Retail Location Please Provide Effective & Expiration Dates
  

ADDITIONAL RETAIL LOCATIONS INFORMATION

Retail Location #2 Address
     
General Liability Limits Required - Retail Location #2

What Is The Retail Location #2 Building Constructed Of?

What Year Was The Retail Location #2 Building Built?

Square Footage Of Retail Location #2 Your Store Occupies

Does The Retail Location #2 Building Have A Sprinkler System?
Yes  No
Does The Retail Location #2 Building Have An Alarm System?
Yes  No
Value/Amount Of Merchandise & Inventory At Location #2

Value/Amount Of Business & Personal Property At Location #2 (cash drawers, computers, etc.)

Estimated Annual Sales At Location #2

Estimated Annual Payroll At Location #2 (if workers comp needed)

Prior Or Current Insurance Carrier At Location #2

If You Have A Lease On The Retail Location #2 Please Provide Effective & Expiration Dates
  



Retail Location #3 Address
     
General Liability Limits Required - Retail Location #3

What Is The Retail Location #3 Building Constructed Of?

What Year Was The Retail Location #3 Building Built?

Square Footage Of Retail Location #3 Your Store Occupies

Does The Retail Location #3 Building Have A Sprinkler System?
Yes  No
Does The Retail Location #3 Building Have An Alarm System?
Yes  No
Value/Amount Of Merchandise & Inventory At Location #3

Value/Amount Of Business & Personal Property At Location #3 (cash drawers, computers, etc.)

Estimated Annual Sales At Location #3

Estimated Annual Payroll At Location #3 (if workers comp needed)

Prior Or Current Insurance Carrier At Location #3

If You Have A Lease On The Retail Location #3 Please Provide Effective & Expiration Dates