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n 0 qn R Th R yn R yn Oc Qd m e e s Oc Oc Oc m
Oc Oc Oc h h h h b b b + &J b b b &J . $ R j T 60 Cutter Mill Road ( Suite 414
Great Neck, NY 11021
516-466-4200 ( HYPERLINK "http://www.butwin.com" www.butwin.com
fax 516-466-4213 no cover page needed
or exit, save and e-mail to allstate@butwin.com
BUSINESS-OWNERS APPLICATION
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Applicants Name: FORMTEXT D B A : F O R M T E X T A d d r e s s : F O R M T E X T A g e n t F O R M T E X T C i t y , S t a t e , Z i p : F O R M T E X T C o n t a c t F O R M T E X T F O R M T E X T C o u n t y : F O R M T E X T F O R M T E X T F O R M T E X T E - m a i l F O R M T E X T F O R M T E X T F O R M T E X T T o w n s h i p : ( S t a t e o f P A o n l y ) F O R M T E X T F O R M T E X T F O R M T E X T P h o n e F O R M T E X T F O R M T E X T F O R M T E X T C o n t a c t & P h o n e : F O R M T E X T F O R M T E X T F a x F O R M T E X T F O R M T E X T E - m a i l & W e b s i t e : F O R M T E X T F O R M T E X T F O R M T E X T F O R M T E X T F O R M C H E C K B O X I n d i v i d u a l F O R M C H E C K B O X P a r t n e r s h i p F O R M C H E C K B O X C o r p o r a t i o n F O R M C H E C K B O X L L C F O R M C H E C K B O X O t h e r : F O R M T E X T E n t i t y i s i n b u s i n e s s f o r : F O R M T E X T Y e a r s o r F O R M C H E C K B O X N e w C o v e r a g e E f f e c t i v e D a t e : F O R M T E X T F O R M T E X T E n t i t y h a v e p r i o r l i a b i l i t y i n s u r a n c e : F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o % I f y e s , F O R M C H E C K B O X 1 y r F O R M C H E C K B O X 2 y r s F O R M C H E C K B O X 3 y r s % A n y l a p s e s d u r i n g t h a t t i m e : F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o % I f y e s , l i s t m o s t r e c e n t I n s u r a n c e C a r r i e r : F O R M T E X T F O R M T E X T D e s c r i b e a l l o p e r a t i o n s : T y p e h e r e & F O R M T E X T
FORMCHECKBOX Office FORMCHECKBOX Retail FORMCHECKBOX Service FORMCHECKBOX Wholesale FORMCHECKBOX Manufacturing FORMCHECKBOX OtherComplete SUPPLEMENTAL APPLICATION with the following businesses: (available at www.butwin.com/allstate)
FORMCHECKBOX Auto Repair/Body Shop FORMCHECKBOX Church FORMCHECKBOX Computer Consulting/Tech/Web FORMCHECKBOX Deli/Convenience Store FORMCHECKBOX RestaurantLoca t i o n : # F O R M T E X T I n t e r e s t : F O R M C H E C K B O X O w n e r F O R M C H E C K B O X T e n a n t A r e a o c c u p i e d b y i n s u r e d : F O R M T E X T s q f t ( u s e a s e p a r a t e a p p l i c a t i o n f o r e a c h l o c a t i o n ) I s t h e b u s i n e s s i n a r e s i d e n c e : F O RMCHECKBOX Yes FORMCHECKBOX No
GENERAL LIABILITY FORMCHECKBOX $300,000 FORMCHECKBOX FORMCHECKBOX $500,000 FORMCHECKBOX FORMCHECKBOX $1,000,000 FORMCHECKBOX FORMCHECKBOX $2,000,000 FORMCHECKBOX FORMCHECKBOX $3,000,000# OF Owners: FORMTEXT O w n e r s A n n u a l P a y r o l l o r D r a w : $ F O R M T E X T # o f F u l l T i m e E m p l o y e e s ( e x c l u d i n g o w n e r s ) : F O R M T E X T A n n u a l P a y r o l l ( e x c l u d i n g o w n e r s ) : $ F O R M T E X T F O R M T E X T # o f P a r t T i m e E m p l o y e e s : F O R M T E X T G r o s s R e c e i p t s : $ F O R M T E X T F O R M T E X T D o e s t h e i n s u r e d h i r e s u b c o n t r a c t o r s : F O R M C H E C K B O X Y e s F O R M C H E C K B O X N o % I f y e s % c o s t o f s u b c o n t r a c t o r s : $ F O R M T E X T P R O P E R T Y B u i l d i n g : $ F O R M T E X T D e d u c t i b l e $ F O R M C H E C K B O X 2 5 0 F O R M C H E C K B O X 5 0 0 F O R M C H E C K B O X 1 , 0 0 0 F O R M C H E C K B O X 2 , 5 0 0 B u s i n e s s C o n t e n t s : $ F O R M T E X T C o m p u t e r s : $ F O R M T E X T N o t e s : F O R M T E X T F O R M T E X T B u s i n e s s I n c o m e / E x t r a E x p e n s e : $ F O R M T E X T F O R M T E X T O u t d o o r S i g n : $ F O R M T E X T F O R M T E X T G l a s s : $ F O R M T E X T F O R M T E X T S p o i l a g e C o v e r a g e : $ F O R M T E X T C a s h o n P r e m i s e s : $ F O R M T E X T E m p l o y e e T h e f t : F O R M C H E C K B O X N o n e F O R M C H E C K B O X $ 1 0 , 0 0 0 F O R M C H E C K B O X 2 0 , 0 0 0 F O R M C H E C K B O X 5 0 , 0 0 0 F O R M C H E C K B O X O t h e r : F O R M T E X T O t h e r P r o p e r t y C o v e r a g e s : F O R M T E X T F O R M T E X T 6 0 C u t t e r M i l l R o a d ( S u i t e 4 1 4
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