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New Location Change Request

Insured Name
Key Contact
First Last
Contact Phone
Contact Email
Physical Address Change?
- Yes
- No
Mailing Address Change?
- Yes
- No
New Office?
- Yes
- No
New Named Insured Entity
FEIN
Will This Location Replace An Existing Office?
- Yes
- No
Are The Contents/Equipment/Other Property To Be Transferred To The New Location?
- Yes
- No
Are You Purchasing The Building?
- Yes
- No
When Does The Coverage Go Into Effect?
MM slash DD slash YYYY
New Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Should We Delete A Location From Your Policy? If So, Please List The Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Building Construction
- Frame
- Joisted Masonry (walls w/ combustible floor & roof)
- Masonry Non-Combustible (masonry walls, concrete floors & on protected steel)
- Metal Roof
- Other
Occupancy/Operation (%Office, %Storage, %Warehouse)
Other Occupants In Building
Is There Any Commercial Cooking In The Building?
- Yes
- No
Description of Operations
WC Class Code
Annual Payroll
GL Payroll
GL Code
Square Footage of Entire Building
Square Footage of Your Occupancy
Number of Building Stories
Annual Rental Income, If Any
Distance To Fire Hydrant
Distance To Fire Department
Protection Class
Building Amount (upload a copy of your appraisal here)
Max. file size: 59 MB.
County
Content Amount
Year Building Was Constructed
If Building Is Over 20, Age of Plumbing
If Building Is Over 20, Age of Electrical
If Building Is Over 20, Age of Heating
If Building Is Over 20, Age of Roofing
Fire Alarm?
- Yes
- No
Burglar Alarm?
- Yes
- No
Sprinkler System?
- Yes
- No
Percentage of Sprinkler System
Mortgage Name
Mortgage Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Landlord Name
Certificate Needed?
- Yes
- No
Disclaimer: Communications to this insurance agency by electronic mail or voice mail CANNOT be considered as binding or otherwise effective for ANY insurance protection/policy coverage. Our office will contact you via e-mail to confirm any information sent and please look for the policy change endorsement to follow. If you do not receive this endorsement from the insurance carrier, contact your agent immediately. Thank you.
Attachements
Max. file size: 59 MB.

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Fairfax Office

Preferred Insurance

4100 Monument Corner Dr
Suite 400
Fairfax, Virginia 22030

Phone: (703) 359-5910

Mon-Thu: 8:30am-5:00pm
Fri: 8:30am-4:30pm
Sat-Sun: Closed

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