PREMISES INFORMATION (Attach ACORD 823 for Additional Permises, if applicable)

CONTACT NAME :

PHONE (A/C, No, Ext) :

FAX (A/C, No) :

E-MAIL ADDRESS :

STREET :

CITY LIMITS


CITY :

STATE :

COUNTY :

ZIP :

DESCRIPTION OF OPERATIONS :

INTEREST


ANNUAL REVENUES : $

OCCUPIED AREA SQFT :

OPEN TO PUBLIC AREA SQFT:

TOTAL BUILDING AREA SQFT:

ANY AREA LEASED TO OTHERS?

NATURE OF BUSINESS

DATE BUSINESS

STARTED (YYYY-MM-DD)

DESCRIPTION OF PRIMARY OPERATIONS

RETAIL STORES OR SERVICE OPERATIONS % OF TOTAL SALES:

INSTALLATION, SERVICE OR REPAIR WORK

OFF PREMISES INSTALLATION, SERVICE OR REPAIR WORK

DESCRIPTION OF OPERATIONS OF OTHER NAMED INSUREDS