For Help Call  770-840-8744 
Fields marked (*) are mandatory.
Broker/Company
Submitted By
Phone Number
Fax Number
E-Mail Address
Effective Date
Select Program(s) you're Interested In
Basic
Comprehensive
Property & Liability
Property only
Liability only
Other
Vesting/Registered Owner Information
Named Insured
Address
City
State
Zip
Contact Person
Phone
Fax
New CIBA Member
Have you been a member of CIBA before?
If Yes, year
current CIBA Member
Approximate number of properties enrolled
Premium Finance Quote Requested
Special Comments
Property Information
Lo?ation Address
City
State
Zip
EQ Zone
Portfolio?
Property Type
Commercial/Industrial
Retail space
Office Building
Warehouse
Apartment Building/Complex
Condominium
Rental Dwelling
Mixed Tenancy
Vacant Land
Nature of Rusinpss/Tenant
Description of Operations
Total Square Footage
# of Units
# of Pools
# of Spas
Fenced?
Building RCV
Annual Rents
Year Built *
Retrofitted? *
* Bull dings built in or before 1969 that do not meet the California Uniform Building code of 1976 do not qualify for comprehensive coverage under the
year Construction type
Number of years property owned hy insured
# of Buildings
# of Stories
Sprinklers
Central Station Alarm
Parking
If Other
a. Are driveways, parking & sidewalks In smooth repair?
If No please explain
b. Are stairs, porches, rails, landings and balconies In good repair?
If No please explain
c. Any graffiti on walls or fences?
If Yes please explain
d. any garbage, debris or Inoperable vehicles on premises?
If Yes please explain
e. Does structure have wood shake roof?
f. Has this property or Insured sustained a loss during the past 5 years?
If yes, please attach a Loss History
Current Insurance Coverages
Commercial General Liability
Insurance Company
Limit
Deductible
Premium
Auto Liability
Insurance Company
Limit
Deductible
Premium
Property -All Risk
Insurance Company
Limit
Deductible
Premium
Property- DIC
Insurance Company
Limit
Deductible
Premium
Non-Habitational: Number of tenants
Tenants Operations
Additional Insured Information
Loan #1
Name
Address
City
State
Zip
Nature of Interest
1st Mortgagee
2nd Mortgagee
3rd Mortgagee
Additional Insured
Loss Payee
438BFUNS Applies
GL 15-1
GL 15-2A
GL 15-2B
Loan #2
Name
Address
City
State
Zip
Nature of Interest
1st Mortgagee
2nd Mortgagee
3rd Mortgagee
Additional Insured
Loss Payee
438BFUNS Applies
GL 15-1
GL 15-2A
GL 15-2B
Loan #3
Name
Address
City
State
Zip
Nature of Interest
1st Mortgagee
2nd Mortgagee
3rd Mortgagee
Additional Insured
Loss Payee
438BFUNS Applies
GL 15-1
GL 15-2A
GL 15-2B
Loan #4
Name
Address
City
State
Zip
Nature of Interest
1st Mortgagee
2nd Mortgagee
3rd Mortgagee
Additional Insured
Loss Payee
438BFUNS Applies
GL 15-1
GL 15-2A
GL 15-2B