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Business Insurance Quote Request









DBA (if applicable):



Mailing Address:









Zip Code:







Contact Person:



Phone Number:



Fax Number:



Email Address:*










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:









Zip Code:







Location Address:









Zip Code:







Location Address:









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













If Building Coverage is desired,
Please complete the following:




Year Built:



Type of Construction:



Protection Class:



Number of Stories:










 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:























Distance to Fire Hydrant:



Distance to Fire Station:



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







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















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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