Upshot Insurance — Producer Intake Sheet

Account / Named Insured

*LLC Name

DBA

FEIN (If Applicable)

*Contact Name

*Phone

*Email

*Address

Additional Named / Additional Insured

Current Insurance

Current Carrier

Current Premium

Property / Building

Owner Or Tenant

*BPP / Inventory

Roof Updated Year

*Property Value

Fire Alarm

Sprinkler %

Hours / Days Of Operation

*Gross Sales

*Annual Payroll

FT Employees

PT Employees

General Notes

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Liquor Store

Alcohol Sales (If Different From Gross Sales)

Late-Night Operations

Hotel / Motel

No. Of Rooms

Occupancy %

Average Daily Rate

No. Of Pools

Elevators (Y/N + #)

Builder's Risk

New Construction / Renovation

Total Completed Value

Existing Building Value

New Building Value Estimate

BPP

Business Income

Project Start

Project Completion

Occupied During Construction

Lessor's Risk Only (LRO)

Tenant Operations

% Occupied

Annual Rental Income

Written Leases

Certs / Add'l Insured

Restaurant Or Liquor Tenant

Gas Station / C-Store

*Gasoline Sales(Gallons)

*Inside / C-Store Sales

*Beer & Wine Sales

*Commercial Cooking Sales

No. Of Pumps

*Canopy Value

Car Wash

Restaurant

*Total Gross Sales

*Food Sales

Alcohol Sales

% Alcohol Sales

*Seating Capacity

*Cooking Type