Software: Apache/2.0.54 (Unix) mod_perl/1.99_09 Perl/v5.8.0 mod_ssl/2.0.54 OpenSSL/0.9.7l DAV/2 FrontPage/5.0.2.2635 PHP/4.4.0 mod_gzip/2.0.26.1a uname -a: Linux snow.he.net 4.4.276-v2-mono-1 #1 SMP Wed Jul 21 11:21:17 PDT 2021 i686 uid=99(nobody) gid=98(nobody) groups=98(nobody) Safe-mode: OFF (not secure) /home/butwin/public_html/allstate/grandslam/forms/ drwxr-xr-x | |
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P a g e 1 o f 2 A p p l i c a n t s N a m e : F O R M T E X T 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 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 H A T M A Y V A R Y , F R O M A T R A D I T I O N A L F L O R I S T :
T y p e h e r e & F O R M T E X T
L o c a 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 sq ft (use a separate application for each location)Is the business in a residence: FORMCHECKBOX 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 R e f r i g e r a t i o n E q u i p m e n t : $ F O R M T E X T P e r i s h a b l e G o o d s : $ F O R M T E X T N o t e 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 F O R M T E X T A l l O t h e r C o n t e n t s : $ 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 O f f - P r e m i s e s S t o r a g e : $ F O R M T E X T M a x i m u m 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
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