Business Owners’ Quote

Please take a few minutes to complete the following information if you would like to obtain a quote.  Please understand, this is not an application.  If coverrage is desired, we will send an application to you.

All information provided is confidential and will be used solely for the purpose of providing a quote for you.

Business Name
Street Address
Zip Code
Phone Number
Alternate Telephone
Fax Number
E-Mail Address
Underwriting Information
What is the nature of your business?
What type entity is the business
Number of Owners or Officers
Number of Employees
Total Annual Payroll of Owners or Owners
Total Annual Payroll of Employees
Total Annual Gross Receipts
Business License Number, if any
License Type, if any
Years of experience
Years operated under current name
Other business names
Is there any manufacturing, mixing, re-labeling or repackaging of products?
Please describe the nature of your business and ANY unusual exposures:
Building & Property Information
Dor You Own the Building or Lease
What is Age of Building
Total square footage of the building your business is in
Total square footage of your business only
How many stories is it?
If two stories, what is the ground floor square footage?
What is the construction type?
What type of roof covering?
Was the roof updated, if owner?
If yes, what year?
Are there smoke detectors at this location?
Are there fire extinguishers?
Are there deadbolts on all exterior doors?
Is the electrical updated?
Is the heating / air conditioning thermostatically controlled?
Is the heating/ air conditioning central?
Has the plumbing been updated?
If yes, what year was the plumbing updated?
Does the building have interior automatic fire sprinklers?
Is there a theft alarm?
Is there a fire alarm?
Claims Information
Were there any losses or claims in the last 5 years?
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?
What is the building limit requested?
What is the building deductible requested?
What is the business personal property (contents) limit requested?
What is the contents deductible requested?
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.
Or Specify Other:

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