Applicant Information |
* Todays Date:
(mm/dd/yyyy) |
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* Owner's First Name: |
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* Owner's Last Name: |
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* Owner's Home Street Address: |
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* City: |
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* State: |
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* Zip: |
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* County: |
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* Valid Email Address:
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* Home Phone:
(999-999-9999) |
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* Work Phone:
(999-999-9999) |
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* Best time to contact you?:
* Best way to contact you?:
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Email
Phone
Work Phone |
Please provide any comments you have: |
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* Are you currently (or have you ever been) a Brooke customer? |
Yes
No |
* How did you hear about Brooke? |
Other: Please Specify
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Insurance Information |
Desired Limits: (Each Occurrence/General Aggregate) Other limits may be available upon request. |
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$300,000/$600,000
$500,000/$1,000,000
$1,000,000/$2,000,000 |
| What percentage, if any, of gross receipts/revenues is derived from service and/or installation of products? |
% |
| What percentage, if any, of gross receipts/revenues is derived from the rental of any equipment? |
% |
| Please indicate whether any of the following optional coverages are desired. The limits provided will be the same as the limits chosen above. |
| Employee Benefits Liability: |
Yes
No |
Liquor Liability: |
Yes
No |
If yes, please provide annual liquor receipts:
$
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| Hired and Non-owned auto liability: |
Yes
No |
Limited International General Liability Extension Endorsement: |
Yes
No |
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| Please indicate whether any of the following exclusions are desired. |
| General Liability Enhancement Endorsement (adds additional insureds and other broadening coverages.): |
Yes
No |
| General Liability Extended Enhancement Endorsement (adds extended property damage and other broadening coverages.): |
Yes
No |
Wholesale Applicants ONLY |
| Are all of the goods manufactored domestically or by a company with a location in the US? |
Yes
No |
| If no is Imported Products Liability coverage desired? |
Yes
No |
| If Imported Porducts Liability Coverage is desired, what are the gross annual sales for foreign manufactured products? |
$
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| Do you do any repacking, re-labeling, repair, or re-manufactoring of products? |
Yes
No |
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