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AREAS OF SPECIALIZATION
BUSINESS INSURANCE
PERSONAL INSURANCE
EMPLOYEE BENEFITS

Add/Change Location

GENERAL INFORMATION
Business Name (incl Corp and T/A names)
Date
Requestor Name & Contact Information (phone / email)
Delete Current Location?
- Yes
- No
Effective Date of Deletion
Address of Location to Delete
Effective date to Add Location
Use New Location for Mailing?
- Yes
- No
New Location Address
LOCATION / BUILDING INFORMATION
Type of building (office, retail strip mall, industrial, etc.)
Owner or Tenant?
Sq Ftg You Occupy
Stories
Approx Year Built
Construction (Frame, Masonry, Noncombustible, Fire Resistive, etc)
% of Bldg Sprinklered
If bldg over 30 yrs old, Year(s) Updated for Wiring, Heating, Plumbing, Roof
Alarm? Burglar or Fire? Local or Central Station?
COVERAGE LIMITS REQUESTED
Building
* Contents Replacement Value
Improvements & Betterments
Business Income & Extra Expense
Computer Hardware
Computer Software (data & media)
Valuable Papers
Accounts Receivable
Exterior Sign?
Building Glass (measurements)
Other Property Used or Stored Off Premises (describe & value)
Total Misc Mobile Tools & Equipment (max $,1000 value per item)
Scheduled Mobile Equipment (for individual items exceeding $1,000 in value)
ATTACH SCHEDULE
Do you rent or loan equipment to others? If Yes, please provide details
- Yes
- No
* Contents may include, but is not limited to: Leasehold Improvements, Leased Property, Inventory, Furniture/Fixtures, Equipment, Printed Materials, Consumables, and Property of Others in Your Care. Please consult your lease requirements when choosing the coverage and limits for this location.
OTHER
** Issue Certificate of Insurance to Landlord?
- Yes
- No
** List Landlord as Additional Insured?
- Yes
- No
Landlord Name and Address:
Comments / Additional Information / Instructions
** Please carefully review your lease for all insurance requirements.

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Germantown, MD 20874
Local: 301-417-0001
Toll-Free: 800-966-0001
Fax: 301-417-0040
customerservice@moodyinsurance.com

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