businessowners

Businessowners
Quote
Form

We are pleased to provide this free, no-obligation quote. Please fill in the form as completely as possible. This information will only be kept and used for quoting purposes.

General Information

Name of Insured:
Address: (street,city, state, zip)
Business Phone:
Business Fax:
Email Address:
Location Address: (type "same" if same as above)

Property Information

Age of Building/Year Built:
Type of Building Construction:
Number of Stories:
Other Occupancies:
Square Feet You Occupy:

If the building is over 25 years old, please answer the following:

Year Electricity was Upgraded:

Is it on Circuit Breakers?

Yes

Year Plumbing was updated:

Copper or Galvanized Plumbing?

Copper

Galvanized

Other:

Year Building was Re-Roofed?

Type of Roofing Material:

Type of heating system in Building:

Protective Devices

Burglar Alarm:	YesNo
Central Station or Local Alarm?:	CentralLocal
Name of Alarm Company:
Is the building sprinklered?	YesNo
Are there Smoke Detectors?	YesNo

Liability Information

Please provide information on previous insurance carrier.

Previous Carrier:
Policy Number:
Proir Premium:
Policy Renewal Date:

Please provide information about your business.

Years In Business:
Projected Annual Gross Receipts:
Projected Annual Payroll:
Describe your business, product or service:

Coverage Limits

Building:
Contents: (equipment, inventory, supplies, ect.)
Deductible:
Loss Of Income:
Money and Securities:
Glass and Signs:
General Liability Limit:
Non Owned and Hired Automobile Liability:
Is Liquor Liability needed?
If glass coverage is needed, please provide the dimensions:	2
Please list other coverages you may need.

Miscellaneous Information

Name of Additional Insureds (Landlord or Vendor)
Additional Insureds Address:

Additional Comments

Please give any additional comments you feel appropriate for this quote. If you have any additional information where there wasn't enough fields above, please list here.