Complete the following information if you would like to obtain a quote. Please understand this is not an application. An application will be sent to you if coverage is desired.
All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.
Personal Information * Last Name * First Name Business Name Street Address City State Zip Code Phone Number Alternate Telephone Fax Number Email Address Underwriting Information What is the nature of your business? Is the business a corporation, partnership, or sole proprietorship? Corporation Partnership Sole Proprietorship Number of owners Number of Employees Payroll of Owners Payroll of Employees Total annual gross receipts Business License Number License Type Years of experience Years operated under current name Other business names Is this business open 24 hours a day? Yes No Any deep frying (food)? Yes No Is there any manufacturing, mixing, re-labeling or repackaging of products? Yes No Is there filling of propane tanks? Yes No Please describe the nature of your business and ANY unusual exposures: Building & Property Information Total square footage of the building your business is in Total square footage of your business only Total square footage of the customer area only How many stories is it? If two stories, what is the ground floor square footage? What is the construction type? -Select- Brick Stone Frame Masonry Superior Log Cabin Frame-Stucco Masonry Veneer What type of roof covering? Was the roof updated? Yes No If yes, what year? What is the distance to fire protection? -Select- 1000 ft or less to hydrant and 5 mi or less to fire station Over 1000 ft to hydrant and 5 MI or less to fire station Over 5 and up to 10 MI to fire station Over 10 MI to fire station Is the business in a brush area? Yes No Do you have a storage area more than 1500 sq. ft? Yes No Are there smoke detectors at this location? Yes No Are there fire extinguishers? Yes No Are there deadbolts on all doors? Yes No Are there circuit breakers? Yes No Is the electrical updated? Yes No Is the heating / air conditioning thermostatically controlled? Yes No Is the heating/ air conditioning central? Yes No Has the plumbing been updated? Yes No If yes, what year was the plumbing updated? Does the building have interior automatic fire sprinklers? Yes No Is there a theft alarm? Yes No Is there a fire alarm? Yes No Are there any restaurants in your building Yes No Are there any restaurants in the building next to your business? Yes No Claims Information Were there any losses or claims in the last 5 years? Yes No If yes, what is the date, amount paid and description of each loss or claim? Coverage Information Current Insurance Company How much are you paying now? What is the liability limit requested? -Select- 100,000 300,000 500,000 1,000,000 What is the building limit requested? What is the building deductible requested? -Select- 250 500 1,000 2,500 What is the business personal property (contents) limit requested? What is the contents deductible requested? -Select- 250 500 1,000 2,500 What is the loss of income requested? Questions or Comments Best Time To Contact You Please let us know the best time to call and discuss your quote. Morning Afternoon Evening Anytime Or Specify Other: Before submitting, type in required validation security code: 6yw9ps