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

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

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

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

Additional Comments
Optional
Submission Validation
Required
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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.

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Judy Carter & Associates   300 Vestavia Parkway   Suite 1600   Birmingham, Alabama 35216