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Note: This input form is for the purpose of gathering information only and does not contitute any additions or changes to new or existing coverage.
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- General Information -

Your Full Name:
*
Your Company :
Address:
City:
  *
State:
Zip:
Business Phone:
 *
Email Address :
 *

- Nightclub Location -

Bar/Nightclub Name
Address
City
State
Zip

- Current Insurance Information -

Company Name
Policy Expiration Date
Current Premium Amount ($)
Years Insured
Any Claims Last 3 Years?



Building Coverage  
Age of Building
Business Property Amount ($)
Ansul Type
Deductible ($)  

- Nightclub Information -
Catering?



DJ?



Patio?



Total Square Footage:
Public Access Sq. Ft. :
Approximate Gross Sales:
Food Sale %:
Alcohol Sale %:
Number of Employees:
Years Insured:
 

 
Additional Comments or Questions

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