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Date when you need coverage to begin:
*We suggest that the effective date of your insurance be no later than the date upon which you take possession of the premises.
Federal Tax ID No:
Applicant is:
Individual Corporation Limited Liability Corp Other (please specify)
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Do you own the Building you’ll be occupying? Yes No
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If yes, what is the replacement cost value of the Building?
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Limit of Business Personal Property coverage desired:
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*This limit is to include any improvements or betterments to your leased space, as well as any equipment, furniture, supplies or products.
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Is there a Bank or any other Financial Institution that you’re using to finance your business that needs to be added
as a Lienholder to your policy? Yes No
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If Yes, give name and address:
Name:
Address:
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Building Construction Type?
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Frame/ Wood
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Brick with Wood Frame Construction
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Brick with Steel Frame
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Tilt up Wall Steel Frame
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Other:
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Total Square Ft. Year Built
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Fire Alarm: YES NO Fire Extinguishers: YES NO
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Burglar Alarm: YES NO
If yes, is it just a local alarm or is it connected to a Central Station?
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Additional Insureds (for Liability Purposes) include:
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1) Facelogic International, 5650 El Camino Real, Suite 125 Carlsbad, CA. 92008
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2) (Lessor)
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Number of Estheticians you intend to hire:
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Total Estimated Annual Payroll (including all Owners & Executive Officers) $ # of Employees
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Names and titles of all Owners & Executive Officers
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In order to receive a written quotation, please complete & submit this form.
Should you have any questions, please call Jason Youens at (254) 753-5317
Note: Your completing this form does not initiate coverage.
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