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Quotation Request Form - All Systems Go™

Please select the location to which you would like to send your quote:

Insured:

Date: / / (mm/dd/yyyy)

Mailing Address:

Occupancy:

Contact Name:

Contact Phone No: () -

Rating Values

Location No. 1

Address of Location:

Heating (if Building owner): Steam/Hot Water Other

Building Value: $

Contents Value:

- Computer hardware: $

- All other electronic equipment
(telephone, fax, copiers, etc.): $

- Furniture and Fixtures
(excluding inventory): $

Rating Value: $

Data Limit: $

Business Interruption Annual Value: $

Deductible Amount: $

Anniversary Date: / / (mm/dd/yyyy)

Date Quotation Required: / / (mm/dd/yyyy)

Prospect Information

Loss History (last 5 years): Yes No

If Yes:

Date of Loss: / / (mm/dd/yyyy)

Object:

Amount paid: $

Existing Broker:

Existing B&M Carrier:

Existing B&M Premium: $

Existing Property Carrier:

Broker Information

Broker Name:

City:

Contact Person:

Phone No.: () -

Fax No.: () -

E-mail:

Notes: