Business Insurance

BUSINESS OWNER QUOTE
First Name:
Last Name:
Business Name:
Address:
City:
State:
Zip Code:
Phone Number:
Fax Number:
E-Mail Address:
UNDERWRITING QUESTIONS
Property County:
Please Describe the Nature of Your Business
Number of Owners:
Number of Employees:
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:
Years of Experience:
How Many Years Have You Operated This Business:
How Many Stories:
Construction Type:
Is This Business Open 24 Hours A Day?	yes no
Any Deep Frying (Food)?	yes no
If An Office Risk, Is E&O With 1 Million Admitted Coverage Carried?	yes no
Fire Extinguisher:	yes no
Deadbolts On All Doors?	yes no
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 Income Coverage:
Liability Limits Requested:
Policy Deductible:
Questions or Comments to help the Agent: