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What type of coverages are you interested in?
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Name of Business
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Contact Name
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Street Address
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City
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State
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Zip
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County
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Email
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Business Phone
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Fax Number
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Current Insurance Company (not agency name)
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Company Name
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Policy Exp. Date
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Current Coverages
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Bonds
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Disability
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Commercial Auto
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Group Health
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Commercial Liability
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Group Life
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Commercial Property
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Professional Liability
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Commercial Umbrella
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Workers' Compensation
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Directors & Officers
Liability
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Other
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Info about Your Business
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# of full-time employees
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# of part-time employees
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How long in business
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How many locations
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Annual Sales $
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Please describe your business operations
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PROPERTY OR PREMISES LOCATION #1
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Street Address
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Owner
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Tenant
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Year Built
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The % you occupy
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What type of Construction: Frame, Brick Veneer, Steel, Masonry, and etc.
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# of Stories
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# of Basements
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Sq. Footage
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Burglar Alarm yes or no
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Building Value $
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Contents Value $
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Other Property
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PROPERTY OR PREMISES LOCATION #2
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Street Address
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Owner
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Tenant
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Year Built
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The % you occupy
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What type of Construction: Frame, Brick Veneer, Steel, Masonry, and etc.
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# of Stories
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# of Basements
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Sq. Footage
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Burglar Alarm yes or no
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Building Value $
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Contents Value $
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Other Property
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PROPERTY OR PREMISES LOCATION #3
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Street Address
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Owner
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Tenant
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Year Built
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The % you occupy
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What type of Construction: Frame, Brick Veneer, Steel, Masonry, and etc.
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# of Stories
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# of Basements
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Sq. Footage
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Burglar Alarm yes or no
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Building Value $
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Contents Value $
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Other Property
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Liability
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Class of business
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Annual Gross Sales (before taxes)
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Number of Employees
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Annualized Payroll
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Cost of any Subcontracted Work
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Limits Requested $300,000 $500,000 $1,000,000 $2,000,000
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Describe any claims you've had in the past 5 years.
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Additional Comments
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