Business Insurance Quote
No coverage is bound until you are contacted by one of our representatives
Name
Business Name
Street Address
Street Address
City, State, Zip
Phone Numbers
Home
Work
Email Address
BUSINESS ACTIVITIES
1.
Type of organization
Select One
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?
Select One
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:
Select One
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:
f. Year Electricity was Updated
g. Is it on Circuit Breakers
Select One
Yes
No
h. Year Plumbing was Updated
i. Copper or Galvanized Plumbing
Select One
Copper
Galvanized
Other
If Other
PROTECTIVE DEVICES:
22. Do you have a security system?
Select One
Yes
No
If yes, please describe what type
Burgler Alarm
Select One
Yes
No
Type of Alarm
Alarm Company
Sprinkler System In Building
Select One
Yes
No
Smoke Detectors
Select One
Yes
No
23. Have you had any property losses in the
past 3 years?
Select One
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:
ADDITIONAL INSURED
Name
Address
Phone Number
Phone
FAX
Account or Loan #
LIENHOLDER/MORTGAGE INFO
Name
Address
Phone #
Fax #
Loan #
Legal Description
Building Owned or
Leased
Select One
Owned
Leased
COMMENTS