P.O.M. PLANNING SERVICES, INC

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Business / Commercial

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Legal Business Name * :

Doing Business As (DBA) :

Telephone Number * :

Email * :

Address * :

Type of Business * :

Size(s/f) :

Construction Type :	Brick Frame Non-combustible Masonry Fire-Resistive Other

Number of Stories:

Gross Sales :	$

Current Insurance Carrier :

Loss/Claim History in the last 3 years :	Yes No

Sprinkler :	Yes No

Burglar/Fire Alarm Type :	Central Station Alarm Local Alarm None

Desired Content Limit (Business Personal Property) :	$

Desired Building Limit :	$

Desired Liability Limit :	$1,000,000 $2,000,000 Over $2,000,000

Workers Compensation Insurance :	I have I don't have

Additional Information :