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Business Name:
Contact Name:
City:
Ownership: Individual Corporation Non-Profit Corporation Partnership Other:
Building Characteristics: Construction Type (select): Frame Brick Non-Combustible
Type of Electric: Fuses: Circuit Breakers:
Type of Heating: Boiler: Gas Forced Air: Space Heaters:
Protection Devices: Smoke Detector: Fire Alarm: Burglar Alarm: Sprinkler: Emergency Lighting:
Please provide a description of the property including any additions or upgrades that should be considered:
Do you repackage, re-label or modify any products of others? Yes No
Completion of this questionnaire does not afford coverage and is used for quoting purposes only.
Thank you!
Hruska Insurancenter, Inc. 10040 W. 190th Place, Mokena, IL 60448 708-798-5700 Fax 708-798-1475 Toll Free 800-827-5525
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