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Business Insurance Quote
No coverage is bound until you are contacted by one of our representatives
Contact Information
Name
Business Name
Street Address
Street Address
City
State
Zip Number
Home Phone
-
-
Work Phone
-
-
Email Address
Business Activities
1. Type of Organization
Corporation
Individual
Limited Liability Corp.
Non-Profit
Partnership
S Corporation
2. How many owners, partners, or officers?
3. How many employees, excluding owners, partners or officers?
4. Date Business Started?
5. Last year's payroll:
6. This year's projected payroll:
7. Last year's gross sales:
8. This year's projected sales:
9. Describe your normal business activities
10. Have you had liability losses or claims in the past 5 years?
Yes
No
If yes, please give description, date and amount paid for each
Property Information
a. Year Building was built
b. Type of building construction:
Frame
Masonry
Aluminum Siding
c. Number of Stories
d. Other Occupancies:
e. Total Square Feet
f. Square Feet You Occupy
IF THE BUILDING IS OVER 25 YEARS OLD, PLEASE ANSWER THE FOLLOWING:
g. Year Electricity was Updated
h. Is it on Circuit Breakers
Yes
No
i. Year Plumbing was Updated
j. Copper or Galvanized Plumbing
Copper
Galvanized
Other
If Other
Protective Devices
22. Do you have a security system?
Yes
No
If yes, please describe what type?
Burglar Alarm
Yes
No
Type of Alarm
Alarm Company
Sprinkler System In Building
Yes
No
Smoke Detectors
Yes
No
23. Have you had any property losses in the past 3 years?
Yes
No
If yes, please describe
Prior Coverage
1. Previous Carrier
2. Policy Number
3. Prior Premium
4. Policy Renewal Date
5. Continuous Coverage in Force Since
Desired Coverage
Liability
Coverage Limit
Property
Coverage Limit
Deductible
Buildings
Coverage Limit
Deductible
Contents
Coverage Limit
Deductible
Signs
Coverage Limit
Deductible
Other
If Other
Coverage Limit
Other
If Other
Coverage Limit
Other
If Other
Coverage Limit
Email Address
Additional Insured
Name
Address
Phone Number
-
-
Fax
-
-
Account or Loan #
Lienholder/Mortgage Info
Name
Address
Phone Number
-
-
Fax
-
-
Loan #
Legal Description
Building Owned or Leased
Owned
Leased