General Information
Name of Business: (if applicable)
Contact Name:
Address:
City:	State:   Zip:
Phone:	Fax:
Contact E-mail Address:

Current Insurance Information
Company Name:
Policy Number:
Policy Expiration Date:
Date you want change to take effect:

Premises Information
Address:
City:	State:   Zip:
City Limits:	Inside   Outside
Interest:	Owner   Tenant
Year Built:
Part Occupied:
Nature of Business or Description of Operations:

Vehicle Information
Car #1	Year	Make	Model	Body Type	Vehicle Identification Number
Use			Drive to school/work? No. of miles		Airbags	GVW / GCW
Commercial Farm Pleasure Retail Service			Under 15 15 or more		Y N
If vehicle is kept at an address other than that listed above, please indicate below
Location City:   State:   Zip:

Car #2	Action: Add Change Delete
	Year	Make	Model	Body Type	Vehicle Identification Number
Use			Drive to school/work? No. of miles		Airbags	GVW / GCW
Commercial Farm Pleasure Retail Service			Under 15 15 or more		Y N
If vehicle is kept at an address other than that listed above, please indicate below
Location City:   State:   Zip:

Driver Information
Driver #1	Driver's Name		Action: Add Change Delete
			Yrs Licensed:		State Licensed:
Relation	Date of Birth	Sex	% Use Vehicle	DL Number
		M F

Driver #2	Driver's Name		Action: Add Change Delete
			Yrs Licensed:		State Licensed:
Relation	Date of Birth	Sex	% Use Vehicle	DL Number
		M F

Inland Marine - Scheduled Equipment
IM #1	Action: Add Change Delete
	Year	Make	Model	Capacity	ID / Serial Number
Date Purchased			Condition		Amount of Insurance
			New Used

IM #2	Action: Add Change Delete
	Year	Make	Model	Capacity	ID / Serial Number
Date Purchased			Condition		Amount of Insurance
			New Used

Umbrella
Limit of Liability:
Retained Limit:
Other, describe:

Additional Interest
Type of Interest:	Additional Insured Loss Payee Mortgagee Lienholder Employee as Lessor
Name:
Address:
City:	State:   Zip:
Certificate Required:	Yes   No
Interest in the following:
Premises:
Building:
Vehicle:
Boat:
Scheduled Item Number:
Other:
Item Description:

Comments or Information