Sole ProprietorLLCCorpPartnership

Store Specifics

Building Class (Frame, Block or Brick):
FrameBlockBrick
Do You Have Fire Sprinklers: YesNo Do You Have Smoke Detectors: YesNo Fire Alarm (Local, Central Station or None): LocalCentral StationNone Burglary Alarm (Local, Central Station or None): LocalCentral StationNone

Attendant Information

Additional Information

Any Fire Loss In Last 5 Years:
YesNo
Any Coverage Declined, Cancelled, Non-Renewed:
YesNo
Do You Lease Out Any Space To Another:
YesNo
Any Major Remodeling In Process:
YesNo
Are You In Receivership Or Bankruptcy:
YesNo

Coverages Requested

Requested Start Date of Policy:

Additional Insured

Disclosures and Agreements

The Applicant agrees to the below terms and instucts Lawrence Larsen CA Insurance Broker License 553938 to process this application and obtain a quote for insurance on their Laundromat business.
1. Coverage and premiums are subject to acceptance in writing by an insurer.
2. All exposures and hazards known to applicant are disclosed.
3. The application is a true description of all operations fo the applicant.
4. Misreprsentation on the application may void all insurance.
Confused on any term used in this application or need help in answering any question or coverage? Call Lawrence Larsen at 714-390-9969 Email Completed Application to: Laundromat123@gmail.com

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