* Red questions are required.
Contact Information
Company:
Street Address:
City:
State:
Zip Code:
Phone Number:
Fax:
Email Address:
Contact Person:
Business Information
Type of Business:
Form of Business:
Choose One
Sole Proprietor
S Corp
C Corp
Partnership
# of years in business:
# of Staff:
# of Locations:
Location Information
Street Address:
City:
State:
Zip Code:
County:
Building Construction:
Choose One
Frame
Joisted Masonry
Non-Combustible
Fire Resistive
Roof Type:
Choose One
Wood
Composite
Flat
Metal
Is the Building Fully Sprinklered:
Yes
No
Fire/Burglar Alarm:
Choose One
Local
Central Station
Police Dept.
Area:
Year Built:
If Building is over 30 years old, enter the years the following components were updated:
Wiring:
Heating:
Plumbing:
Roof:
Number of Stories:
Business Personal Property Value:
$
Building Value (If Owned):
$
Annual Sales/Receipts:
$
For Businesses selling the following: Optical Goods, Prescription Goods and Hearing Aides what is the % of Professional Sales to Annual Sales?:
%
Annual Payroll:
$
Deductible:
$
Coverage Information
Computers/Media Limit:
$
Valuable Papers Limit:
$
Personal Property of Others Limit:
$
Sewer/Drain Backup Limit:
$
Accounts Receivable Limit:
$
Property In Transit Limit:
$
Employee Dishonesty Limit:
$
Forgery and Alterations Limit:
$
Maximum Value Of Leased Equipment:
$
Installation Value Per Project:
$
Please Explain Any Other Coverage Requirements:
Please note: Completion of this form is for quotation purposes only and does not create a contract of insurance of any kind.
