Business Owner

 

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Business Owner's Insurance Quote Form

Please complete the following form and click the "Send Quote" button to 
submit for a free Business owner's quote.

BUSINESS OWNER QUOTE SHEET

 
First Name:  
Last Name:  
Business Name:  
Mailing Address:  
Mailing City:  
Mailing State:
Mailing Zip Code:  
Phone Number:
Fax Number:
E-Mail Address:  

UNDERWRITING QUESTIONS

 
Property Address:
Property City:
Property State:
Property Zip Code:
Property County:
Please Describe the Nature of Your Business
Number of Owners:
Number of Employees:
Payroll of Owners:
Payroll of Employees:
Total Annual Gross Receipts:
Total Square Footage of the Building Your Business Is In:
Square Footage Of Your Business Only:
Current Insurance Company:
Business License Number:
License Type:
Years of Experience:
How Many Years Have You Operated This Business:
How Many Stories:    
If Two Stories, Ground Floor Square Footage:  
Total Square Footage of Your Dwelling:  
Construction Type:         
Roof Type:           
Roof Updated: yes no 
If Yes, Year Roof was Updated:
Protection Distance:        
Is The Business In A Brush Area? yes no 
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 Filing Of Propane Tanks? yes no 
Is There Storage More Than 1500 Sq Ft? yes no 
If An Office Risk, Is E&O With 1 Million Admitted Coverage Carried? yes no 
Are There Smoke Detectors At This Location? yes no 
Smoke Alarm: yesno
Fire Extinguisher: yesno 
Deadbolts On All Doors? yesno
Circuit Breakers: yes no
Electrical Updated:   
Heating - Air Conditioning, Thermostatically Controlled?: yesno 
Heating - Air Conditioning, Central? yes no 
Plumbing Updated: yesno
If Yes, Year Plumbing was Updated:
Interior Automatic Fire Sprinklers:       
Theft Alarm:      
Fire Alarm:    
Losses-Claims in the last 5 years:              
If yes, date, amount paid and description of each loss-claim

COVERAGE INFORMATION

 
Building Coverage:
Other Structures Coverage:
Business Contents Coverage:
Loss of Use Coverage:
Liability Limits Requested:        
Policy Deductible:        
Questions or Comments

 

 

 

 

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