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*Name of Organization:
*Phone: *Email Address:
Address: Line 2
Part Occupied: Other Occupancies:
Denomination: # of Members:
Property Section:
Building Limits: Deductible:
Contents Limits: Deductible:
Business Income: Extra Expense:
Year Built: No. of Stories:
# of Apts:
(if any)
Sq. Ft. of Building:
Mortgagee: Sq. Ft. Occupied:
Burglar Alarm:    
Fire Alarm: Fire Protection:
Fine Arts:
Musical Instruments: Deductible:
Equipment: Deductible:
Commercial General Liability:
General Aggregate: Each Occurance:
Day Care Operation: # of Kids: Ages:
After School Program: # of Students: Ages:
Elementary School: # of Kids: Ages:
Any Additional Liability Coverages:
Prior Carrier:    
Company: Expiration Date:
Annual Premium: Losses:
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