Business Quote Request

Contact Information
Contact Name:
Contact Address 1:
Contact Address 2:
Contact City, State: ,
Contact Zip
Contact Phone:
Contact Fax:
Contact Email:
Business Name:
Business Address 1:
Business Address 2:
Business City, State: ,
Business Zip
Business Phone:
Business Fax:
Business Email:
Underwriting Information
Nature of your business:
Business Type: Corporation    Partnership Sole Proprietor
Numbers of Owners: Numbers of Employees:
Payroll of Owners: Payroll of Employees:
Business License Type: Business License Number:
Annual Gross Reciepts: Years of Experience:
Other business names: Yes   No Years Under Current Name:
Open 24 hours a day: Yes    No Any deep frying (food): Yes    No
Filling of Propane Tanks: Yes    No Manufacturing, mixing or relabelling of products: Yes    No
Any unusual exposures:
Building and Property Information
Building square footage: Business square footage:
Customer area square footage: Nunber of stories:
Construction Type: Type of roof covering:
What is the distance of fire protection? Is the business in a brush area? Yes No
Storage area more than 1500 sqft? Yes No Smoke detectors: Yes No
Fire Extinquishers: Yes No Deadbolts on all doors: Yes No
Circuit breakers: Yes No Is the electrical updated:
Thermostatic Heat/Air Yes No Central Heat/Air : Yes No
Plumbing updated: Yes No If yes, what year?
Automatic Fire Sprinklers: Yes No Burglar alarm: Yes No
Fire alarm: Yes No Restaurants in building: Yes No
Restaurants next door: Yes No    
       
Claims Information:
Claims or losses in last 5 years: Yes No    
Please explain:
Coverage Information:
Current insurance company: Current Premium
Liability limit requested? Building limit requested?
Building deductible requested? Business contents limit requested?
Contents deductible requested? Loss of income requested?
Business Auto Garaging Information:
Garaging Address:    
     
  ,    
Driver Information:
Driver 1 Name:
Gender: Male    Female
Marital Status:
Years Licensed:
State Licensed:
License Type
Driver 2 Name:
Gender: Male    Female
Marital Status:
Years Licensed:
State Licensed:
License Type
Driver 3 Name:
Gender: Male    Female
Marital Status:
Years Licensed:
State Licensed:
License Type:
Driver 4 Name:
Gender: Male    Female
Marital Status:
Years Licensed:
State Licensed
License Type
Vehicle Information
Vehicle 1 Year:
Make:
Model:
ID Number:
G.V.W.:
Miles Per Year:
Radius Driven (average):
Ownership:
Vehicle 2 Year:
Make:
Model:
ID Number:
G.V.W.
Miles Per Year:
Radius Driven (average):
Ownership:
Vehicle 3 Year:
Make:
Model:
ID Number:
G.V.W.:
Miles Per Year:
Radius Driven (average):
Ownership:
Vehicle 4 Year:
Make:
Model:
ID Number:
G.V.W.:
Miles Per Year:
Radius Driven (average):
Ownership:
Violation Information
  Driver 1 Driver 2 Driver 3 Driver 4
Minor Violations - speeding, turn, stop sign, red light (past 3 years)
Accidents - non-chargeable (past 3 years)
Accidents - chargeable (past 5 years)
Major violations - drunk driving, reckless, hit and run, etc (past 5 years)
Coverage Information
  Bodily Injury Property Damage  
Personal Liability  
Uninsured motorist  
Medical payment    
Deductible Information
  Vehicle 1 Vehicle 2 Vehicle 3 Vehicle 4
Comp (theft)
Collision
       
Miscellaneous Information
Current Policy Expiration:    
Any questions, comments or additional coverage required?

        

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