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AUTO | BOND | BUILDING | CONTRACTORS | EARTHQUAKE | EVENTS | GARAGE | LIABILITY | WORKERS COMP

 
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General Information

Insured's Name
Phone Number
Fax Number
Email Address
Insured is:
Business Name
Street Address
City
Zip Code CA

Area SqFt.

Year Built
Annual Payroll
Annual Receipts
Liquor Sales

Loss History
 
Prior carrier and loss history for the past three years
From Mo. Yr. To Mo. Yr.
Company Name
Policy number
Cancelled or Non-renewed
Reason


Coverages Desired:
General Liability
Assault & Battery Liability Yes , No
Liquor Liability Yes , No

Business Personal property & Contents

Business Interruption
Sign Coverage
Food Spoilage Yes , No

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AUTO | BOND | BUILDING | CONTRACTORS | EARTHQUAKE | EVENTS | GARAGE | LIABILITY | WORKERS COMP

 

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TELEPHONE (310) 551-1235 & (310) 551-1236 Fax (310) 551-1250
400 South Beverly Drive, Suite 318, Beverly Hills, Ca 90212. USA.
E-MAIL sales@concordgeneralinsurance.com

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