Current Insurance Information
Company Name (not agency):
Policy Expiration Date:		Premium Amount: $
Current General Liability Limits:		$   Current Liquor Limits: $
What type of coverages do you currently have:
Building value (own / lease):			Contents value:
Current Deductible:			RC or ACV Coins:
Year of Last Mechanical Update:			Property Form:
Age of Building:			Number of Stories:
Construction Type:			Total Square Footage:
Square Footage You Occupy:			Miles From Coast:
Miles From Fire Dept/Hydrant:

About Your Facilities
Do you have restaurant/ kitchen facilities?:	y   n       Annual Food Sales $
Do you have a bar?:	y n     Open to public?: y n     Annual Sales $
Current Membership:

Aerie Information

Does your aerie engage in any turkey shoots, fireworks displays, carnivals, have any lakes, parades, ball fields or swimming pools?:   Yes  No If so, which: Turkey Shoots         Fireworks Displays         Carnivals         Lakes Parades         Ball Fields         Swimming Pools

Does the aerie offer bingo? Yes No Open to public? Yes No Is liquor sold during bingo?    Yes No

Does the aerie have any employees? Yes No     Annual Payrolls? $

Does the aerie own any autos? Yes No     If so, what:

Miscellaneous Information

Describe any losses in the last five years:

Any other coverages: (Employee Dishonesty, Money & Securities, Business Income, etc.)

Additional Comments

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