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Name of Business:
Contact Name:
Address:
City:
 State: Zip:
Business Phone:
 Fax Number:
Contact Email Address:
Property Information
Address of Property:
Property City:
Property State:
Property Zip:
New purchase Existing ownership
Number of units:
Building Square footage:
Year Built:
Occupancy:
Owner Tenant
Occupancy Type:
Plumbing type:
 Copper Galvanized Mixed (Copper/Galvanized)
Foundation Type:
 Slab
Crawlspace over slab
Pier & Post
 Other (list in remarks)
Type finished basement, if any:
 None Full 25% 50% 75%
Type Roof:
 Shingle
Wood Shake
Tar/Gravel
Spanish Tile
Metal
Other
Type of Siding:
 Brick Vinyl Wood Aluminum
Number of stories:
 1 2 3 4 or more
# of feet to nearest fire hydrant:
# of miles to nearest fire station:
Currently Insured?
Name of Carrier & how long insured?
 Yes No
Coverage's
Building Coverage
 $
Liability Coverage
 $
Contents
 $
Deductible $
($250, $500, $1,000, etc.)
 $
Other Coverage/Remarks:
(describe any extra coverage's needed such as business interruption, robbery, computers, etc.):
Any claims reported on this property or previously owned properties in the last 3 years?
 Yes No
Please describe: Include date(s) and details of claim:

Additional Comments
Please give any additional comments or questions

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Gordon Insurance Associates, Inc.
8251 West Thunderbird Road, Ste 160
Peoria, Arizona 85381
Office: (623) 486-6815
Fax:     (888) 870-9690
Email: info@giasite.com

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