WILLIAM E. CASEY INSURER SERVICES One Nipmuc Road, Paxton, MA 01612 Phone: (508) 265-5969 / Fax: (508) 791-3312 http://www.wcinsurerservices.com/ ORDER FORM Customer Name: Requestor: Request Date: Wed, 10 Mar 2010 03:39:10 -0500 Policy #: Due Date: Service Type: Standard Service   Rush Required Account/Insured: Contact: Telephone (Home): (Work): Location: City, State, Zip: , Agency: Telephone: Describe Type of Risk: Comments:   PROPERTY        CASUALTY        WARRANT Coverage Perils        Liability          Building Fire        Products        Central Station Burglar Alarm Contents Wind        OL&T        Central Station Fire Alarm Mercantile All Risk        M&C        Sprinklers Builders Risk Flood        Vacant        Automatic Extinguishing System with semi-annual cleaning contract Narrative Required Photos Required:   Front   Back          No Deep Fat Frying or Grilling on premises        Smoke Detectors        Building Locked & Secured        Heat maintained at 50%