1820 East 1st Street
Santa Ana, CA 92705
714-569-2700
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Chem®Dry General Liability and Property Insurance Application
Meets all Harris Research Inc Insurance Requirements for “General Liability“

Ownership
Business Name Franchise Number(s)
Owners Name Contact Name  
Phone   Fax
Email Address     # of Years in Business

Mailing Address 		  Location Address (If different from mailing address)
Street
City
State, Zip ,   
Street
City
State, Zip ,   

Proposed		      
Policy Starting Date End Date


Location Information    (Applicable whether you run the business from your home or an office)
Year Built # of stories
Total Square
Footage		    (Office and/or shop combined)
Construction
Protection

If building is over 20 years old, list the year of the following improvements / updates :
  Wiring Roofing Heating
  Plumbing Other
     
     
 
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