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First & Last Name:
Location Street Address:
City, State & Zip:
E-Mail Address:
Telephone:
Fax:
Business Name:
Insurance Company Name:
Policy Exp. Date:
Any Claims in Last 3 years?
(if Yes, please describe)
Do you carry work comp for your managers?
Please select..
Yes
No
Property Information
Address (if different):
Year Built:
Protection Devices:
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Central Alarm
Smoke Detectors
Fire Extinguisher
Sprinklers
Any Updates to Property?
(if Yes, please describe)
Complete Lender Info.
ie Escrow Info if new purchase
Building Information
Units:
How many Stories?:
# of buildings:
Flood Insurance?
Please select..
Yes
No
Electrical Type:
Construction Type:
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Wood Frame
Steel
Mill
Concrete
Total Sq. Ft. of building (s):
Earthquake Insurance?
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Yes
No
Building Value:
Contents Value:
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Please give a detailed description of you business and operations:
Note: By submitting this form you understand that no coverage is bound until you receive written notice. You also agree to release us from any liability if this information is accidentally viewed by unauthorized persons. We will only use this information for insurance quoting purposes and not distribute to other parties.
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Tri-County Insurance
800 Industrial Drive S #206
Sauk Rapids, Minnesota 56379
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Phone: 320-251-2552
Fax: 320-253-5682
Toll Free: 888-480-1677
53 Hwy 23 E
Foley, MN 56329
Toll Free: 888-480-2552
Phone: 320-968-6496
Fax: 320-968-9913
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License #20203998 | A Division of JT, Inc. Agency