Property/Liability Insurance Application For Self-Service / Exterior Car Wash

GENERAL INFORMATION
MAILING ADDRESS
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LOCATION ADDRESS
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ADDITIONAL INFORMATION
Does named insured have ownership interest in any other business? If yes, describe on the line below the operation, name, relationship, percentage of ownership, location address for other business. If no, just put "no" on the line below.
CARRIER & PREMIUM INFORMATION
Enter Up To 3 Carriers
ENTER ALL CLAIMS AND OCCURRENCES FOR THE PRIOR 3 YEARS
Enter Up To 4 Claims
TYPE OF CAR WASH
UNDERWRITING AND COVERAGE INFORMATION
Other Profit Centers [indicate those applicable]
If building over 25 yrs indicate year updated
Property Limit: Replacement Cost
Additional Interests
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Agent Mailling Address Copy
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NOTICE OF INSURANCE INFORMATION PRACTICES - Personal information about you, including information from a credit report may be collected from persons other than you in connection with this application for insurance and subsequent policy renewals. Such information as well as other personal and privileged information collected by us or our agents may in certain circumstances be disclosed to third parties without your authorization. You have the right to review your personal information in our files and can request correction of any inaccuracies. A more detailed description of your rights and our practices regarding such information is available upon request. Contact your agent or broker for instructions on how to submit a request to us. ACORD 125 (2005/06) This application does not bind the applicant, the company, or the agent to complete the insurance, but it is agreed that the information contained herein shall be the basis of the contract should a policy be issued.