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Business Insurance Quote Request

 

 

 

 

 

Name:*

 

 

DBA (if applicable):

 

 

Mailing Address:

 

 

City:

 

 

State:

 

 

Zip Code:

 

 

 

 

 

 

Contact Person:

 

 

Phone Number:

 

 

Fax Number:

 

 

Email Address:*

 

 

Website:

 

 

 

 

 

 

Nature of Business:

 

 

Year Started:

 

 

Type of Business:

 

 

Any Bankruptcies in last Five Years?

 Yes    No

 

 

 

 

 

 

Prior Coverage?

 Yes    No

 

 

If Yes, Please Provide:

 

 

 

With Whom:

 

 

When Coverage Ended:

 

 

(The insurance carrier, may request loss runs from previous/current carrier or a no loss statement)

 

 

 

 

 

 

Any Claims/Losses Last Three Years?

 Yes    No

 

 

If Yes, Please provide details:

 

 

 

Location Address:

 

 

City:

 

 

State:

 

 

Zip Code:

 

 

 

 

 

 

Location Address:

 

 

City:

 

 

State:

 

 

Zip Code:

 

 

 

 

 

 

Location Address:

 

 

City:

 

 

State:

 

 

Zip Code:

 

 

 

 

 

 

If Lessors Risk, please advise occupancy:

 

 

Also, if lessors risk we would recommend that the lessor have the tenant carry their own insurance for their business and name the lessor as additional insured.
(It may also likely be a requirement of the insurance carrier – and a certificate of insurance may be requested)

 

 

 

 

 

 

Type of Coverage Seeking:

 

 

Liability = Trip / Fall etc.
Property = Building, Business Personal

If they desire property coverage, discuss if they would like loss of income / rent

Loss of Income /Rent / Extra Expenses = Written under many different forms

 

 

 

 

 

 

 

Standard Liability Coverages:
1,000,000 General Aggregate
1,000,000 Products/Complete Ops Aggregate
1,000,000 Personal & Advertising Injury
1,000,000 Occurrence
50,000 Damage to Rented Premises
2,000 Medical Payments

 

 

 

Square Footage:

 

 

Annual Receipts:

 

 

Annual Payroll:

 

 

Acres (if vacant land):

 

 

The above is by location.  So if there are additional locations, please list separately in box below.

 

 

 

 

 

Any Additional Insured Endorsements Required:

 

 

 

If Yes, please provide:

 Yes    No

 

 

Name:

 

 

Address:

 

 

 

 

 

 

If Building Coverage is desired,
Please complete the following:

 

 

 

Year Built:

 

 

Type of Construction:

 

 

Protection Class:

 

 

Number of Stories:

 

 

 

 

 

 

 

 

Alarm:

 Yes   No

 

 

If Yes, is it a Central Station?

 Yes   No

 

 

If Yes, who is it monitored by?

 

 

 

 

 

 

Exposure to Right:

 

 

Exposure to Left:

 

 

Exposure to Front:

 

 

Exposure to Back:

 

 

 

 

 

 

Updates

 

 

 

Roof:

 

 

Electric:

 

 

Plumbing:

 

 

Heating:

 

 

Distance to Fire Hydrant:

 

 

Distance to Fire Station:

 

 

If BPP (Business Personal Property) coverage is desired, please advise:

 

 

 

Amount:

 

 

If Loss of Rent/Income is desired, please advise:

 

 

 

 

Amount:

 

 

 

 

 

 

 

 

 

Exposures / Classifications that would be subject to a supplemental application:

 

 

 

  • Apartments
  • Auto Dealers
  • Auto Repair Shops
  • Beauty Parlor / Barber Shop
  • Bowling Alley
  • Contractors
  • Daycares
  • Fitness Center / Gym
  • Hotel / Motel
  • Restaurants
  • Tanning Salon
  • Taverns
  • Trucking
  • Vacant Buildings

 

 

 

         

 

 

 

 

 

 

 * Indicates required field

 

 

 

 

 

 

 

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