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Need to report a new or additional office location? If you are a current policy holder, use our simple form below. Completion of this form does not bind or alter your coverage. A representative from Marsh USA, Inc. will contact you.

Firm Name:
State:
Request Type :	New Location Delete Location; #
Date Effective :	mm dd yyyy
Location Address:

Location County:
	City: State: ZIP:

Building Specifications

Are you the tenant or owner of the building?
	Tenant Owner
Year Built:
If the building is over 30 years old, please provide year of updates:
	Wiring: Roof: Plumbing: HVAC:
Construction Type:
Office Building?	Yes No
Number of floors:
Sprinklers:	%
Do you occupy the entire building? Yes No
How many square feet do you occupy?

Coverages (please provide replacement cost limits)

Building:	$
Contents:	$ (Excluding computer hardware, media, data, phones, faxes and copiers)
Engineering Equipment:	$ (Equipment taken more than 1000ft. off insured premises that is owned, leased, borrowed or rented)
Computers & Media:	$ (Including data, phones, faxes and copiers)
Other buildings or storage locations ? Yes No
Landlord/Mortgagee on property? Yes No
If you answered yes, please fill in his/her contact information below
Name:
Address:

	City: State: ZIP:

Special Instructions and Requirements

Requested By:
Date Requested:

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This is a communication from Marsh USA Inc., the Program Administrator.
The ACEC Business Insurance Trust, together with Marsh USA, Inc., makes available both Business Insurance and Professional Liability Insurance.