General Information

*Contact Name:

*Email:

General Business Information

*Business Name:

Address:

City:

State:

Zip:

County:

Business Phone:

- -

Fax:

- -

Current Insurance Company-Not Agency

Company Name:

Policy Expiration Date:

/ /

Current Insurance Coverage

Current Coverages:

(Select all that apply)

Business Information

# of Full-Time Employees:

# of Part-Time Employees:

How long in Business:

How many locations:

Please give a brief description of your business and clientele:

(chars left: 300)

Property/Premises Information

Address:

Occupancy Status:

Year Built:

% Occupied:

Sprinklers:

Construction Type:

Stories:

# Basements:

Square Footage:

Burglar Alarm:

Building Value:

$

Content Value:

$

Other Property-specify:

(chars left: 300)

Insurance Information

Other:

Annual Gross Sales: before taxes:

$

# of Employees:

Annual Payroll:

$

Cost of any Subcontracted Work:

$

Limits Requested:

Describe any claims you've had in the past 5 years:

(chars left: 300)

Additional Comments:

(chars left: 300)

Disclaimer Notice - The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.

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General Information

Current Insurance Company-Not Agency

Business Information

Property/Premises Information

Insurance Information