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Apartment Buildings, Office & Industrial Complexes

CALIFORNIA, ARIZONA, NEVADA, ONLY

Corporation       Individual       Partnership        Other

Name *
Email Address *
Company
Mailing Address
Subject Address
City
County
State
Zip Code
Phone Number
Fax Number
Contact Person
General Liability Limits
Amount of Building Coverage
Business Income
(Actual Loss Sustained)

Number of Buildings
Number of Stories
Age of Building
Roof Update
Plumbing Update
Heat/Air Update
Number of Units Per Building
Square Footage
If over 25 years, provide year of:
Electrical Update
Swimming Pool                                    Yes No
Fire Sprinklers                                     Yes No

Construction Type
Current Carrier
Policy Number Exp. Date
Premium
   
Specify Losses in the Last 3 Years