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Convenience Store Questionnaire

Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Company Information
Company Name *
First Name *
Last Name *
Street *
City *
State *
ZIP / Postal Code *
E-Mail Address *
Primary Phone Number *
Alternate Phone Number
Fax Number:
Premises Address:
Hours of Operation:
Additional Information
Age of building:
Building square footage:
Construction of building:
Age of Updates on Building:
Electrical Update (yes/no. If yes, include year of update):
Plumbing Update (yes/no. If yes, include year of update):
Heating Update (yes/no. If yes, include year of update):
Roof Update (yes/no. If yes, include year of update):
Value of Building:
Number of pumps:
Total Gallons Sold:
Do you have a car wash?

If yes, please enter receipts from car wash:
Total Annual Sales/Receipts - Gas:
Total Annual Sales/Receipts - Liquor:
Total Annual Sales/Receipts - Restaurant:
Total Annual Sales/Receipts - All Other:
Company Owner *
Years in Business:
Years of Experience:
Are you currently insured?

Current Insurance Provider
Effective date of coverage:
/ /
Losses in past 5 years:
Amount of loss:
Date of loss:
/ /
Have you been cancelled?

If yes, please list the reason:
Describe your cooking exposure:
Do you have a check cashing service?

Additional Comments
Submission Validation

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.
Judy Carter & Associates   300 Vestavia Parkway   Suite 1600   Birmingham, Alabama 35216