Business Owners Quote
About You
Full Name*:
Business Name*:
Contact Phone Number*:
Fax Number:
Email Address:
Street Address*:
City*:
State*:
Zip*:
Name of Current Insurance Company*:
How Long Have You Been Insured
With That Company*?
Less than a Year
1-3 Years
3-5 Years
5-10 Years
Over 10 Years
About the Property
Age Of Building/Year Built*:
Type Of Building Construction*:
Stucco
Masonry/Brick
Fire Resistive
Frame
Other
Number of Stories*:
Other Occupancies*:
Square Feet You Occupy*:
If the building is over 25 years old
Year Electricity Was Updated:
Is It On Circuit Breakers?
Yes
No
Year Plumbing Was Updated:
Copper Or Galvanized Plumbing?
Copper
Galvanized
Other
If other, please specify:
Year Building Was Last Re-Roofed:
Type Of Roofing Material:
Type Of Heating System In The Building:
Burglar Alarm:
Yes
No
Central Station Or Local Alarm?
Central Station
Local Alarm
Name Of Alarm Company:
Is The Building Sprinklered?
Yes
No
Are There Smoke Detectors?
Yes
No
About Your Business
Years In Business*:
Projected Gross Annual Receipts*:
Projected Annual Payroll*:
Describe Your Business,
Product Or Service*:
Coverages
Building*:
Contents (Equipment,
Inventory, Supplies, Etc)*:
Deductible*:
$100
$250
$500
$1,000
Loss Of Income*:
Money And Securities*:
Glass Or Signs*:
General Liability Limit*:
$500,000
$1,000,000
$2,000,000
Non-Owned And Hired
Automobile Liability*:
Is Liquor Liability Needed*?
Yes
No
Comments or Questions:
Deliver quote via*:
Email
Fax
Regular Mail
Telephone
Items marked with a * are required
IMPORTANT! I have read and understand the following:
By checking this box and submitting this form you agree that no policy changes are made, no coverage is bound, and no policy is in effect until you are contacted by one of our representatives. Your information is held in the strictest confidence and is only gathered for the purposes of providing you service with your insurance needs. To more correctly assess your needs; please provide the most accurate information possible.
