Business Change Request

No coverage is bound and no policy is effective until you are contacted by one of our representatives.

Property Information

Add Delete Change Premises Address City, State, Zip Georgia Alabama Alaska Arizona Arkansas Armed Forces Asia Armed Forces Europe Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Florida Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming County Interest Type Tenant Owner Is the distance to responding fire station less than 5 miles? Yes No Is the premises located within the city limits? Yes No Building Limit Personal Property Limit Computer Equipment Limit Software & Media Limit Other Limit Construction Type Select One Frame Brick Veneer Joisted Masonry Masonry Non-Combustible Non-Combustible Fire Resistive Year Built Total Square Feet of the building? (All floors excluding Basement) Total Square Feet you Occupy Number of Stories Number of Basements Any other Occupancies Including Habitational Yes No If yes, please list

If the building is over 15 years old, please answer the following:

Year Roof was Updated Year Electricity was Updated Is it on Circuit Breakers Yes No Year Plumbing was Updated Copper or Galvanized Plumbing Select One Copper Galvanized      If Other Year HVAC was Updated

Protective Devices

Less than 1,000 from Hydrant? Yes No Is Building Sprinklered? Yes No Fire Alarm Type Central Station Local None Burglar Alarm Type Central Station Local None Who is the Service Provider Smoke Detectors Yes No

Additional Insured

Add Delete Change Name of Additional Insured Address Phone # Fax # Attention Account or Loan # Interest Select One Manager / Lessor of premises Owners or Contractors Designated Person / Organization Vendor Other

Loss Payee / Mortagee

Add Delete Change Name of Interest Holder Address Phone # Fax # Attention Loan # Description of Property

Workers Compensation

Add Delete Change Federal Employer ID # State Georgia Alabama Alaska Arizona Arkansas Armed Forces Asia Armed Forces Europe Armed Forces Pacific California Colorado Connecticut Delaware District of Columbia Florida Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Class Code Classification Payroll How many Full Time employees, excluding owners, partners or officers? How many Part Time employees, excluding owners, partners or officers?     Officers / Owners Name Title Job Duties Percentage of Ownership Payroll (including any bonuses or commissions) Does the officer/owner wish to be Included or Excluded? Included Excluded

General Liability

Add Delete Change Classification Payroll Amount Sales / Receipts

Any change in operations?

Comments

	October 2008 Newsletter from The McCart Group AIG Update - October 1 2008 AIG Security Update, and Additional Thoughts to Consider September 2008 Newsletter from The McCart Group

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