Corporate Page
We would like to provide you with a free n0- obligation insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.
Business Owners Package
General Information
Name of Insured:
Address:
City:
  State:   Zip:
Business Phone:
  Fax Number:
Email Address:
Location Address 
(type "same" if same as above):
City:
  State:   Zip:

 

Property Questions
Age of building
/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:

Type of heating system in the building:

 

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:
$
$
   
Describe your business, product or service:

 

Coverage Limits
Building:
Contents (equipment,
inventory, supplies, etc.):
Deductible:
Loss of Income:
$
$
$
Money and Securities:
Glass or signs:
General Liability Limit:
Non-owned and Hired
Automobile Liability:
Is liquor liability needed?
$
$
$
Yes   No
   
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:

 

Additional Comments
Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough fields above, please enter them here.