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Personal Information
Full Name:
Address:
City:    State:    Zip:
Daytime Phone:    Night Phone:
E-mail Address:
 
 
Current Insurance Information
Company Name:
Policy Exp. Date:  
Types of coverage you currently have:  
Bonds
Auto
Property & Liability
Workers Comp
Directors & Officers
Group Life & Health
Prof. Liability
Other:
 
 
About Your Business
No. of full-time employees:

No. of part-time employees:

Years in business:
No. of locations:

Annual sales:


Please give a complete description of your operations:
 
 
Property Questions
Age of building
or year built:
Type of building
construction:
Number of
stories:
Other
occupancies:
Square feet
you occupy:
sq. ft.
If the building is over 25 years old, please answer the following:
Year electricity was updated:

Is it on circuit breakers?:

Yes   No

 

Year plumbing was updated:
Copper or galvanized plumbing?: Copper   Galvanized  
Other:

 

Year building was last re-roofed:
Type of roofing material:
 
 
Protective Devices
Burglar Alarm:
Central Station
or local alarm?:
Name of
alarm company:
Is the building
sprinklered?:
Are there
smoke detectors?:
Y N
  Central Station
 
Local Alarm
Y N
Y N
 
 
Liability Questions
Please provide information on previous insurance carrier:
Previous Ins. Carrier:
Policy number:
Prior premium:
Policy renewal date:
$
Please provide information about your business:
Years in business:
Projected gross annual receipts:
Projected annual payroll:
$
$
 
 
Coverage Limits
Building:
Contents
(equipment, inventory, supplies, etc)
Deductible:
Loss of Income:
$
$
$
Money & Securities:
Glass or signs:
General Liability Limit:
Non-owned & Hired
Auto Liability:
Is liquor liability needed?
$
$
Y N
Y N

If glass coverage is needed, please provide dimensions:

Please list other coverages you may need:

 
 
Miscellaneous Information
Name of Additional Insured
(Landlord or vendor):
Mailing Address:
City:   State:   Zip:
 
 
Comments or Information

 

 
 

Please click on the "Submit Quote" button to send your quote request.
This is a request for quotation only. No coverage is in effect
until bound by an insurance carrier.