Businessowners

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

UNDERWRITING QUESTIONS

COVERAGE INFORMATION