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Contact Name*:
E-Mail*:
Name of Company or Organization:
Address:
City:
Zip:
	OwnLease
How many years have you been in business:	yrs. mo.
Hours of operation:
Security Burglar Alarm Hold up Button
Value of contents, stock/furnishing (US$)?:
Annual Sales (US$)?:
Do you know your deductible (US$)?:
Have you had any claims in the past five years:	YesNo
Describe the nature of your business:
Current estimated Value of Building including all lease hold improvements (US$):
Current Estimated Value of all Business Personal Property (not attached to bldg) (US$):
Current Estimated Value of all Business Computers, Point of Sales Computers, Telephone Systems, Fax Machines, etc(Do not included this value in Personal Property above) (US$):
Current Estimated Average Inventory (if applicable) (US$):
Current Estimated Annual Business Income (US$):
Current Estimated Annual Payroll (US$):
Number of Full Time Employees:
Number of Part Time Employees: