We would like to provide you
with a free, no-obligation insurance quote. Please provide as
much information possible for the most accurate quote. This information
will be kept confidential and will be used for quote purposes only.
General Information
Name
of Insured:
Address:
City:
State:
Zip:
Business
Phone:
Fax Number:
Email Address:
Location
Address
(type "same" if same as above):
City:
State:
Zip:
Property Questions
Age of building
/Year Built:
Type of building
construction:
Number of
stories:
Other
occupancies:
Square feet
you occupy:
sq.
ft.
If the building is over 25 years old, please answer
the following:
Year Electricity
was updated:
Is it on circuit breakers?:
Yes No
Year Plumbing
was updated:
Copper or Galvanized plumbing?:
Copper Galvanized Other:
Year Building
was last re-roofed:
Type of roofing material:
Type of heating
system in the building:
Protective Devices
Burglar Alarm:
Central Station
or local alarm?:
Name of
alarm company:
Is the building
sprinklered?:
Are there
smoke detectors?:
Y N
Central
Station
Local
Alarm
Y N
Y N
Liability Questions
Please provide information on previous insurance
carrier:
Previous Ins. Carrier:
Policy number:
Prior premium:
Policy renewal date:
$
Please provide information about your business:
Years in business:
Projected Gross annual receipts:
Projected annual payroll:
$
$
Describe your business,
product or service:
Coverage Limits
Building:
Contents (equipment,
inventory, supplies, etc.):
Deductible:
Loss of Income:
$
$
$
Money and Securities:
Glass or signs:
General Liability Limit:
Non-owned and Hired
Automobile Liability:
Is liquor liability needed?
$
$
$
Yes No
If Glass
Coverage is needed, please provide dimensions:
Please
list other coverages you may need:
Miscellaneous Information
Name of Additional Insured
(Landlord or vendor):
Mailing Address:
City:
State:
Zip:
Additional Comments
Please give any additional comments you feel appropriate
for this quotation. If you have additional information where there was
not enough fields above, please enter them here.
Please click on the "Submit Quote" button to send
your quote request.
One of our representatives will respond to your submission as
soon as possible.
