COMMERCIAL INSURANCE QUOTE REQUEST |
The following information is needed to provide an insurance quote. Use this as a guide as to what information is needed if you would like to obtain an Business Insurance quote. An application will be sent to you if coverage is desired. All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you. |
| Personal Information |
| What is your name? | Last | |
First | |
Middle | |
| What is your business name? | Business Name | |
| What is your address? | Street | |
City | |
State | |
Zip | |
| What is your telephone number? | Home | |
Business | |
| What is your fax number? | Fax | |
| What is your email address? | Email | |
| Underwriting Information |
| What is the nature of your business? | Nature of Business
|
| Is the business a corporation, partnership or sole proprietorship? |
Corporation
Partnership
Sole Proprietorship |
| How many owners? | Number of Owners | |
| How many employees? | Number of Employees | |
| What is the payroll amount of the owners? | Payroll of Owners | |
| What is the payroll amount of the employees? | Payroll of Employees | |
| What is the total annual gross? | Total Annual Gross Receipts | |
| What is the business license number? | Business License Number | |
| What is the license type? | License Type | |
| Years of experience in this business? | Years of Experience | |
| How many years have you operated under your current business name? | Years Operated Under Current Name | |
| Have you used any other business names during the past 5 years? | Other Business Names | Yes No |
| Is this business open 24 hours a day | Open 24 Hours | Yes No |
| Any deep frying (food)? | Deep Frying | Yes No |
| Is there any manufacturing, mixing, re-labeling or repackaging of products? | Manufacturing | Yes No |
| Is there filling of propane tanks? | Propane Tank Filling | Yes No |
| Please describe the nature of your business and ANY unusual exposures. | Unusual Exposures
|
| Building & Property Information |
| What is the total square footage of the building your business is in? | Total Square Footage of Business Building | |
| What is the total square footage of your business only? | Total Square Footage of Business Only | |
| What is the square footage of the customer area only? | Square Footage of Customer Area | |
| How many stories is it? | Stories | |
| If it's two stories, what is the ground floor square footage? | Ground Floor Square Footage | |
| What is the construction type? | Construction Type | |
| What type roof covering? | |
| Was the roof updated? | Roof Updated | Yes No |
| If yes, what year? | Year Roof Updated | |
What is the distance of fire protection?
|
| Is the business in a brush area? | Brush | Yes No |
| Do you have a storage area more than 1500 Sq. Ft.? | Storage Area | Yes No |
| Are there smoke detectors at this location? | Smoke Detectors | Yes No |
| Are there fire extinguishers? | Fire Extinguishers | Yes No |
| Are there deadbolts on all doors? | Deadbolts | Yes No |
| Are there circuit breakers? | Circuit Breakers | Yes No |
| Is the electrical updated? | Electrical Update | |
| Is the heating/ air conditioning thermostatically controlled? | Thermostatically Controlled | Yes No |
| Is the heating/ air conditioning central? | Central | Yes No |
| Has the plumbing been updated? | Plumbing Updated | Yes No |
| If yes, what year was the plumbing updated? | Year Plumbing Update | |
| Does the building have interior automatic fire sprinklers? | Automatic Fire Sprinklers | Yes No |
| Is there a theft alarm? | Theft Alarm | Yes No |
| Is there a fire alarm? | Fire Alarm | Yes No |
| Are there any restaurants in your building | Restaurants | Yes No |
| Are there any restaurants in the building next to your business? | Restaurants Next to Business | Yes No |
| Claims Information |
| Where there any losses or claims in the last 5 years? | Losses - Claims | Yes No |
| If yes, what is the date, amount paid and description of each loss or claim? | |
| Coverage Information |
| What is the current insurance company? |
|
| How much are you paying now? | Amount Current Coverage | |
| What is the liability limit requested? | Liability Limit | |
| What is the building limit requested? | Building Limit | |
| What is the building deductible requested? | Building Deductible | |
| What is the business personal property (contents) limit requested? | Business Personal Property | |
| What is the contents deductible requested? | Contents Deductible | |
| What is the loss of income requested? | Loss of Income Coverage | |
| Are there any questions, comments or additional coverage required? | Questions, Comments or Additional Coverage |