GARAGE INSURANCE

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GARAGE INSURANCE QUOTE FORM
Your Name:
Business Name:
City:
State:
Zip Code:
Phone Number:*
Fax Number:	(Only fill in if you'd like quote faxed)
E-Mail Address:*
Construction Type:
Theft Alarm:
Fire Extinguisher:	yes no
Circuit Breakers:	yes no
Interior Automatic Fire Sprinklers:
Please Describe the Nature of Your Business
Number of Owners:
Number of Employees that work on vehicle:
Payroll of Employees:
Total Annual Gross Receipts:
Years of Experience:
How many years have you operated under your current business name:
Average value of vehicles stored overnight:
Prior coverage ever been declined:	No Yes
Ever file bankruptcy:	No Yes
Losses-Claims in the last 5 years:
If yes, date, amount paid and description of each loss-claim
Building Limit Requested:
Office Contents Limit Requested:
Shop Contents Limit Requested:
Deductible Requested:
Loss of Income Limit Requested:
Liability Limits Requested:
Questions or Comments to help the Agent:
We will deliver a quote to you by the next business day!