BUSINESS
PROPERTY & LIABILITY POLICY QUOTE REQUEST
BUSINESS
INFORMATION
Business
Name:
Contact Name:
Contact Title:
Phone:
Fax:
Website:
E-Mail:
Physical address:
Physical
address2:
City:
State:
Zip Code:
Mailing address if different:
Address:
Address2:
City:
State:
Zip Code:
Federal ID # or
Social Security Number:
Entity
is:
How
were you referred to us?
Description of Business
(at least 3 sentences):
Annual gross receipts:
What are your business
hours:
Date business started:
Years of Owner's
Experience:
Number of employees:
Workers Comp. Insurance Carrier:
Workers Comp. policy renewal date:
Describe the types
of surrounding businesses:
Right side:
Left side:
Behind:
Are you an owner
or tenant of the building:
If owner, building $ limit:
If owner, building square footage:
If tenant, square ft of leased area:
Any off-site storage locations:
TENANTS
AND OWNERS PLEASE COMPLETE ALL OF THE FOLLOWING:
Business Personal
Property (Contents) Limit:
Computer/Media Limit:
Preferred General
Liability Limit:
Building Construction
(choose one):
Joisted Masonry
Central burglar
alarm:
If yes, specify alarm company name:
Fire alarm:
Sprinklers on ceiling:
Building stories:
Building age:
If over 30 years old, last year the following
were updated:
Plumbing
Roof
Electrical
Heating
Other
Current Business Property & Liability
insurance carrier (if any):
Current policy number:
Current policy renewal date:
Current policy premium:
Any claims in the last 5 years (if yes,
please forward loss history):
Remarks and/or special instructions:
SUBMIT
QUOTE REQUEST
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