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* Your Name:
Bus. Location - Street:
Town:
*Zip:
Additional Locations:
* Your Company Name:
* Email:
Website Address:
Phone Number:
Best Time to Call: Morning Afternoon Evening
Brief Description of Business:
Size of Building:
Owner / Tennant:
Central Alarm System: Yes No
Value of Contents:
Do You Sell Autos: Yes No
Do You Have an Approved Spray Booth: Yes No
# of Employees in Shop: Full Time Part Time
Construction of Building: Frame Masonry Steel Combination
Any Gasoline Sales: Yes No
If yes, Annual Receipts:
Do you have Dealer Plates: Yes No
Area You Occupy:
Sprinkler System: Yes No
Age of Building:
# of Stories:
# of Bays:
Number of Business Automobiles :
Current Insurance Company:
Date Current Policy Expires:
Any Claims in the Past Three Years?: Yes No
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