SERVICE STATION / CONVENIENCE STORE / REPAIR SHOP QUOTE FORM (Acord 125) Today's Date: QUOTE TAKER'S NAME: Email Address What is your corporation's Name: What is your DBA: What is your location Address: City: State: Zip Code: What is your First Name: What is your Last Name: What is your Home Phone Number: Fax Number: Cell Number: Other Numbers: What type of Business: GAST ST C-STR CARWASH REPAIR DELI COOKING CHKCASH  What are your hours of operation: Do you have your federal ID Number available: What is your current insurance company: Expiration Date: Current Premium:   DO YOU HAVE ANY CLAIMS OR LOSSES: (Only if this business HAS OR HAS HAD insurance, REQUEST 3-YEAR LOSS RUNS) Say: "PLEASE FAX US YOUR 3-YEAR LOSS HISTORY" PROPERTY SECTION (Acord 140) How many buildings are on the premises: How many coverage do you need for building #1: How many coverage do you need for building #2: What is the square footage of building #1: What is the square footage of building #2: How much contents coverage do you need: Car wash EQUIP. Coverage: How many pumps do you have: How much pumps coverage do you need: How much canopy coverage do you need: Is your canopy attached to the building: How much you need Business income Coverage: Crime Coverage: What is your building construction type: What year was it build: Central Station Alarm : Yes No Sprinkler System: Yes No LIABILITY SECTION (Acord 126) How much liability coverage do you need: In order to provide you with the best possible quote, please provide the following figures: Gross annual C-Store Sales: $ Gasoline Gallons per year: Beer & Wine Sales: $ Cooking/Deli Sales: $ Annual Car wash Sales: $ Check Cashing Sales: $ If Repair shop, # of Mechanic(s): Repair shop Sales: $ NOTES