Commercial Buyback

Commercial Deductible Buyback Policy
Agency Name
Agency Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Producer Name
Producer Email
example@example.com
Insured Name
Insured Email*
example@example.com
Insured Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Property Location Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Distance to coast
Enter distance in miles
Policy Effective Date

MonthDayYear
Date
Policy Expiration Date

MonthDayYear
Date
Basis of Cover
Coverages: Buildings
Coverages: Other Structures
Coverages: Contents
Coverages: Business Interruptions
Occupancy
Construction
Square Footage
Number of Stories
Year Built
Year Fully Updated
Roof Year
Overlying Commercial Insurance Carrier Name
Overlying Commercial Insurance Deductible % (Your current deductible)
3yr Loss History – Wind Only (include DOL &payout amount)
Include DOL & payout amount
Buydown Deductible Percentage or Dollar Amount

PercentageDollar Amount
Buydown Deductible Requested %
Buydown Deductible Dollar Amount
Should be Empty: