1. Equipment Breakdown Coverage requested? Yes No 2. Premises information: a. Premises No.: Building No.: Interest: Address: Amount ACV/Repl. Cause of Coverage Coins. % Deductible Requested Cost Loss Building $ % $ $ Business $ % $ $ Personal Property $ % N/A N/A Business Income Other $ % $ $ Mortgagee or loss payee: • Construction type: • Protection class: • Number of stories: • Total square foot area: • Sprinkler system? Yes No • Operable smoke detectors? Yes No • Is structure enclosed? Yes No • Spray painting operations? Yes No • If yes, is spray paint booth UL approved? Yes No Burglar alarm type: Local Central Station • Fire alarm type: Local Central Station • Year built: • Building remodeling (include year): • Wiring? Yes No Year: Heating? Yes No Year: Plumbing? Yes No Year: Roof? Yes No Year: Are flammables stored in separate, well ventilated fire divisions away from ignition • sources in accordance with specific guidelines? Yes No Premises No.: Building No.: Interest: b. Address: Amount ACV/Repl. Cause of Coverage % Deductible Requested Cost Loss $ % $ $ Building Business $ % $ $ Personal Property
1. Equipment Breakdown Coverage requested? Yes No 2. Premises information: a. Premises No.: Building No.: Interest: Address: Coverage Amount Requested Coins. % ACV/Repl. Cost Cause of Loss Deductible Building $ % $ $ Business Personal Property $ % $ $ Business Income $ % N/A N/A Other $ % $ $ • Mortgagee or loss payee: • Construction type: • Protection class: • Number of stories: • Total square foot area: • Sprinkler system? Yes No • Operable smoke detectors? Yes No • Is structure enclosed? Yes No • Spray painting operations? Yes No If yes, is spray paint booth UL approved? Yes No • Burglar alarm type: Local Central Station • Fire alarm type: Local Central Station • Year built: • Building remodeling (include year): Wiring? Yes No Year: Heating? Yes No Year: Plumbing? Yes No Year: Roof? Yes No Year: • Are flammables stored in separate, well ventilated fire divisions away from ignition sources in accordance with specific guidelines? Yes No b. Premises No.: Building No.: Interest: Address: Coverage Amount Requested % ACV/Repl. Cost Cause of Loss Deductible Building $ % $ $ Business Personal Property $ % $ $