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posted by Anonymous on Wed, 07/13/2011 - 14:41

Galaxy Insurance Service Inc
2403 East Anaheim St.
Long Beach, CA 90804
Phone (562) 438-7000 , Fax (562) 438-7001
http://www.galaxyinsurance.com/
info@galaxyinsurance.com
CA Lic #0D44460 * = required

Effective Date *

Month

Day

Year

Applicant Information

First Name *

Last Name *

Business Name / Applicant Name *

Business *

Indicate Program Requested *

Physical Address

Street *

Suite *

Zip Code *

City *

Mailing Address

Street *

Suite *

City *

Zip Code *

Contact Name for Inspection *

Contact Phone Number (xxx)xxx-xxxx *

Nature of Business

Years in Business *

Hours of Operation *

Days of Operation *

Gross Receipts Annually Sales * $

Description of *

Operations / Occupancy *

Surrounding Exposures & Other Occupancies *

Year Built *

Year Electrical Update *

Year Plumbing Update *

Year Roof Update *

Type of Roof *

Square Feet * ft

Inside City Limits *

Yes

No

Distance to Hydrant (ft) *

Distance to Firestation (miles) *

Fire and Alarm Protection *

Sublease *

Yes

No

Sprinkler *

Yes

No

Fire Extinguisher *

Yes

No

Fire and Alarm Protection *

Local

Central

Property

Building

Limit $

Deductible $

Construction Type *

Total Square Feet * ft

Personal Property

Limit $

Deductible $

Number of Stores * $

Sprinklers

Yes

No

Is It Finished

Yes

No

Basement Present

Yes

No

Liability

(choose the limit options compatible with the program you are requesting)

Liability Limits *

Aggregate $

Occurence $

Hired / Non-Owned Auto $

Prior Policy (ies) / Loss History

Previous Carrier

Number of Losses Last 3 Years *

Total Losses $

Description of Losses

How Many Years of Prior Coverage

What is the Effective Date of the Last Policy

Please account for all the time this business has been open without insurance and give a reason why they were uninsured:

GENERAL INFORMATION

(Please Explain All "Yes" Responses)

6. For retail stores, does installation, service or repair work account for more than 15% of receipts? *

Yes

No

7. Any bankruptcies, tax or credit liens against the applicant in the past 5 years? *

Yes

No

8. Is all equipment inspected annually and well maintained? *

Yes

No

5. Are you involved in manufacturing, mixing, relabeling or repackaging of products? *

Yes

No

2. Any policy or coverage declined, cancelled or non-renewed during the prior 3 years? Not applicable in MO. *

Yes

No

4. Any other insurance with this company? (List Policy Numbers) *

Yes

No

1. Do / have past, present or discontinued operations involde(d) storing, treating, discharging, applying, disposing, or transp *

Yes

No

3. Do you own or operate any other business? *

Yes

No

Additional Interest

Interest

City

Name

Street

Suite

Zip Code

Loan Number

Reference Number

Certificate Required

Yes

No

Remarks

Email Address *

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