Free Property/Liability Quote

The Application below should be filled out as completely as possible in order to receive an accurate quote. Remember this insurance coverage is a coin laundry association insurance program requiring membership in the Coin Laundry Association or purchasing the CLA Loss Control Program.

PLEASE NOTE: Not all coverages are available in all areas.

If you have any questions, you may call CLA Insurance coordinator toll free at 1-800-346-8424. Please, fill out a separate application for each coin laundry.

ALSO: Upon submitting each page, the information is stored for 24 hours as long as you do not delete your cookies associated with Coin Laundry Insurance Site.

* Required Fields

* Date:
* Are you currently a member of CLA?:
CLA membership #:
How did you hear about the CLA Insurance Program?
A. GENERAL INFORMATION
* Insured name (owner of Coin Laundry) the name of, either a person, partnership, or corporation:
* Name of Coin Laundry or the name your doing business as:
Individual partnership, corporation, or other:
* Mailing Address (street or P.O. Box):
* City:
* State:
* County:
* Zip Code:
* Contact Name (the person who will be in charge of insurance):
* Phone Number (work):
*E-mail Address
* Phone Number (Home):
Fax Number:
* Date you need coverage to begin (check your current policy):
* How many years have you owned your laundry?
What is the name of your current insurance company?
How much premium are you paying now?
How much premium have you been quoted for your renewal?
Has any carrier declined, cancelled, or non-renewed your insurance within the past three years? (Do not answer in Missouri)	yes no

If yes, please explain:

List losses, date of claim and amount paid from your present carrier for the last three (3) years. This is required for each location prior to coverage being bound. A Loss Run is not required for a No Obligation Quote; however, quotes can be altered or withdrawn upon receipt of negative reports.

In the boxes below, enter the quantity for each type of washers, dryers, etc. that are currently in your laundry.

* Number of: (Must enter a number even if it is zero)
Top Load Washers:
Front Load Washers:
Single Dryers:
Stack Dryers (double pocket):
Extractors:
Changers:
Vending Machines: