200 E. Sandpointe Ave. Ste. 310
Santa Ana, CA 92707

Phone: (714) 918-0914
Fax: (714) 918-0922

email: info@kleincosta.com

Premises Only

Insurance Agency AGENT
Your Name  
Your Email Address  
Your Phone Number  
California, Nevada or Hawaii License Number
enter “broker” if you already have a broker agreement with us

Name of Insured INSURED
Address of Insured  
Address of Premises Only  
Description of Operations on Premises  
Area in Square Feet  
Total Annual Payroll  
Total Annual Sales  
List Additional Insureds and Their Insurable Interest
if none, enter “none”
List any special Landlord requirements, such as primary and non-contributing wording or waiver of subrogation or other
if none, enter “none”
NOTE: All Fields Must Be Completed