Contact First Name

Contact Last Name

Contact Phone

Email

General Facility Information

Facility Name

Facility Address

Facility City

Facility State

Facility Zip

Streets Paved

  Please Select One Yes No

Facility Lighting

  Please Select One Complete Partial None

Is there any vacant land?

  Please Select One Yes No

Any Lakes, Ponds, or Creeks on Facility Land

  Please Select One Yes No

Distance to nearest Fire Station (in miles)

Distance to nearest Fire Hydrant (in feet)

Other Info

Is there outdoor storage for Boats, RVs, etc?

  Please Select One Yes No

Are there surveillance systems at facility?

  Please Select One Not Applicable Yes No

Is the facility fenced with locking gates?

  Please Select One Not Applicable Yes No

Employee Information

Do you have employees at the facility perform maintenance or repair work?

  Please Select One Yes No

If yes, please describe the work they conduct:

Number of Employees

Do your employees perform relocation services?

  Please Select One Not Applicable Yes No

  Please Select One Yes No

Do you utilize Independent Contractors for facility business?

  Please Select One Yes No

If yes, please describe and give approximate $ payments made to them per year.

Please describe any additional property you want insured (signs, fences, equipment, etc)