 |
No coverage is bound. You will
be contacted by one of our representatives. |
|
| Name: |
|
| Business Name: |
|
| Type of Business: |
|
| Street Address: |
|
| Street Address2: |
|
| City, State, Zip: |
|
| Phone: |
|
| E-mail: |
|
| Mailing Address, if different from above: |
|
| City, State, Zip, if different from above: |
|
| Business Activities |
|
| Type of Organization: |
|
| How many owners, partners, or officers? |
|
| How many employees, excluding owners, partners
or officers? |
|
| How many years have you been in business? |
|
| What was the amount of last year’s payroll? |
|
| What is this year’s projected payroll? |
|
| What is this year’s projected sales? |
|
| What is the amount of building coverage needed? |
|
| What is the amount of contents coverage needed? |
|
| What is the number of vehicles owned? |
|
| Describe your normal business activities: |
|
| Prior Insurance? |
|
| If yes, name of prior insurance company: |
|
| Has coverage ever been non-renewed or canceled? |
|
| If yes, Please explain reason for non-renewal
or cancellation. |
|
| Have you had losses or claims in the past 5
years? |
|
| If yes, Please describe, and provide the date
and amount paid for each. |
|
| |
|
| Coverage Selection |
|
|
Property |
General Liability |
|
Business Auto |
Workers Comp |
|
Umbrella Liability |
Crime |
|
Equipment |
Builder’s Risk |
|
Professional Liability |
Directors & Officers Liability |
|
Bonds |
Other:
|
| |
|
