CGA Associates Boiler Application
We would like to provide you with a free, no-obligation insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.
STEP 1 of 2
Submitting Information
Name of Insured:
Date Proposed Effected:
Address:
City:
State:
ZIP:
Email:
County:
Number of Boilers:
Inspection Contact:
Phone #:
Nature of Business:
(choose one)
Building Owner
Tenant
(
Please complete the Cold Storage or Manufacturing with Production Machinery section, if applicable
)
100% Building Replacement Cost
(per location)
Age of Buildings:
Renovated:
100% Contents Replacement Cost
(per location)
Limits Desired:
Property Damage:
Business Interruption:
Annual Business Income Value(s)
Net
Gross
Package Deductible
$1000
$2500
$5000
Other
Any B & M losses in the last 5 years?
yes
no
Comments on Loss Info:
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