Business Entity is a(n)*	Association Corporation Individual Venture Non-Profit Org Partnership LLC S-Corp
Doing Business As:  (Leave Blank if no Business Name)	(Only fill in if there is a Business Name)
First Name of Applicant:	*
Last Name of Applicant:	*
Location Address:	* (No PO Boxes)
City:	*
State, Zip:	Georgia                             *
County:	*
Applicant's Phone Number:	* ex. 716-837-8804
Applicant’s E-Mail Address:	*
Applicant’s Birthday
Describe Business:	*
Fire sprinkler system	Yes       No
Monitored Burglar System	Yes       No
Personal Property Protection Level: (coverage for desks, tools, supplies, etc)
Sign coverage
Hired/Non Owned Auto Coverage: (extend liability coverage to autos hired      or not owned when used for business)	Yes       No

BUSINESS SUMMARY

Years In Business:	*
Years Experience:	*
Number of owners :	*
Employees:(No owners or clerical)	Full Time *  Part Time *  Part Time Employees work less than 120 days per year
Total Payroll: (Do not enter commas)	*(No owners or clerical)
Annual Gross Receipts:	* (do not enter commas or dollar signs)
Currently have General Liability coverage? :	Yes No *

LIABILITY INFORMATION

Liability Limits 1: ($)	300/600 500/1,000 1,000/2,000 2,000/4,000	Liability Limits 2: (optional): ($)	300/600 500/1,000 1,000/2,000 2,000/4,000
Deductible Level   Option 1:		$500.00 $1,000.00 $1,500.00 $2,000.00 $2,500.00   Option 2  $500.00 $1,000.00 $1,500.00 $2,000.00 $2,500.00

SUBMISSION OF THIS APPLICATION IN NO WAY CONSTITUTES A RECIEPT OF QUOTATION OR APPROVAL FOR BINDING. BINDING WILL BE CONFIRMED BY A WRITTEN RELEASE OF A BINDER NUMBER AFTER ALL REQUIREMENTS ARE RECEIVED IN OUR OFFICE. RATE IS BASED ON INFORMATION PROVIDED ON THIS APPLICATION AND IS SUBJECT TO CHANGE.