<p> G L A S S A P P L I C A T I O N </p><p>(Coverage placed with US Plate Glass Insurance Company) </p><p>Producer Name: </p><p>Agency: </p><p>Address: City: ZIP: </p><p>Phone: Fax: </p><p>APPLICATION </p><p>Insured’s Name: </p><p>Address of Risk: </p><p>Mailing Address (If different): </p><p>Occupancy of Risk: Effective Date: Quote Only </p><p>Note: Coverage cannot be effective until the risk has been inspected and approved by the company. </p><p>Contact Name : Phone No: </p><p>The section below pertains to condominium risks. If this is a non habitational risk, please submit a schedule of glass with measurements, if available. If not available, a survey will be performed to determine the glass schedule. </p><p>Total number of units in building: Are these Villas or Townhouses? Yes No (Please circle one)</p><p>Full (Common area glass and unit glass) </p><p>Units up to 1,200 sq. ft. Total number of floors in building: </p><p>Units from 1,200 to 3,000 sq. ft. Units with shutters: % </p><p>Units from 3,000 to 5,000 sq. ft. Impact Glass: </p><p>Units over 5,000 sq. ft. Units: No Yes % </p><p>Common Area: No Yes % Please complete application and return. Quote will be faxed to your agency upon receipt from the company. </p><p>Best Regards, </p><p>Production Underwriter 400 Colonial Center Parkway Suite 100 Lake Mary, FL 32476 www.seacoastunderwriters.com</p>