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Business Insurance Request Form
Business
Name
*
Mrs
Mr
Ms
Baby
Master
Prof
Dr
Gen
Rep
Sen
St
Contact Phone Number
Email
*
Mailing Address
*
Type of Insurance Needed
- Select Value -
Business Owners Policy
Workers Compensation
Commercial Auto
Bonds
Disability
Briefly Describe Business
Business Information
Business Entity Type
Corporation
LLC
Profit
Sole Proprietor
Tax ID OR Fed ID#
Is this a Home Based Business?
Yes
No
How many years have you been in business?
Have you had any claims in the last 5 years?
Yes
No
Liability Limits Needed:
- Select Value -
100000 - 200000
200
500000 - 1000000
100
2000000 - 4000000
Annual Gross Sales
Number of Full Time Employees:
Number of Part Time Employees:
What is your annual payroll:
Building Information
Is your building?
Leased
Owned
What year was the building built?
Construction Type
- Select Value -
Framed
Joisted Masonry
Masonry - Non Combustable
Metal
Brick
Block
How many square feet is your building?
What is the estimated square footage available for parking?
Do you have a Burglar Alarm?
Yes
No
Do you have a Fire Alarm?
Yes
No
What is your building replacement cost?
Deductible Needed:
- Select Value -
250.00
500.00
1000.00
1500.00
2000.00
2500.00
Business Personal Property Limit?
Deductible Needed:
- Select Value -
250.00
500.00
1000.00
1500.00
2000.00
2500.00
Schedule Coverage
How soon would you like coverage to begin?
Any Comments or Instructions:
Do you agree that by submitting this form you are not covered with insurance. Coverage of Insurance begins when we recieve your signature and payment. We will send confirmation binder once policy is bound.
Yes
No
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