Insured's Information |
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| Insured's Name: |
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| If part of a larger group, i.e. a Diocese, please name your sub-group, parish, etc.: |
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| Insured's Address |
| Address 1: |
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| Address 2: |
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| P.O. Box/Apt.: |
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| City: |
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| State: |
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| Zip Code: |
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| Your Name: |
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| Your Telephone Number: |
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| Your Email: |
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| Fax Number: |
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Addition Information |
| Addition Date: |
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| Property Address |
| Address 1: |
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| Address 2: |
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| P.O. Box/Apt.: |
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| City: |
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| State: |
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| Zip + 4: |
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| County: |
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Construction Type
Please indicate percentage; indicate '0' if not applicable or unknown.
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| Frame % |
Joisted Masonry % |
| Noncombustible/Metal % |
Masonry Noncombustible % |
| Modified Fire Resistive % |
Fire Resistive % |
| Other % |
| If "Other", please describe: |
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| Square Footage: |
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| Number of Stories: |
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| Year Built: |
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Protections (ex: fire alarm, sprinklers, etc.):
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| Replacement Cose Value of Building (not market value): |
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| Replacement Cose Value of Contents (not market value): |
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| Will this building be owned or leased? |
| Owned |
Leased |
| Occupancy/Type of Building (ex: Dwelling, Church, Hall, Kitchen, etc.): |
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| If Occupancy/Type of Building is a school, please provide the following information: |
| Number of Students: |
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| Number of Teachers: |
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| Age Range: |
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| Date of last Valuation/Appraisal: |
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| Is this location mortgaged: |
| Yes |
No |
| If YES, Bank's name: |
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| Bank's Address |
| Address 1: |
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| Address 2: |
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| P.O. Box/Apt.: |
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| City: |
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| State: |
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| Zip Code: |
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| Loan Number: |
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| Loan Amount: |
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Additional Notes:
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Enter Security Code as shown below:
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