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Busines Name:
First Name:   Last Name:
Phone:   Fax:
Street:   City:
State:   Zip:
County:   Email:
WebSite:   How Long In
Business:
Other Occupancies:   OtherOccupancies:
Building Limits:   Content Limits:
Building Age:   Construction Type:
Building Improvements

Wiring:   Plumbing:
HVAC:   Roof:
Limit Of Liability:   Annual Sales:
Annual Payroll:   Current Carrier:
No. Full Time Employees:   No. Part Time Employees:
Please list claims in the last 5 years.

Date Of Loss:
 
Amount Paid:
 
Claim Detail:
 
Open/Closed:
Date Of Loss:
 
Amount Paid:
 
Claim Detail:
 
Open/Closed:
Date Of Loss:
 
Amount Paid:
 
Claim Detail:
 
Open/Closed:
Date Of Loss:
 
Amount Paid:
 
Claim Detail:
 
Open/Closed:
Additional Comments/Questions

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412-816-1000 Mon-Fri 8AM-5:00PM Email: infopinnacle4ins@gmailcom
Pinnacle Group 3301 William Penn Highway Pittsburgh, PA 15235