Commercial Insurance

Name of business:
Contact Name:
Corp/Partnership/Indiv/ Assoc: (choose one)
List Business Owners:
Description of Business:
Mailing Adress:
Phone:
Email Address:
Current insurance carrier:

What type of coverage are you looking for?:

How long have you been in business:		Losses?:
What type of losses:		Number of employees:
How many F/T:		How many P/T:

How much in payroll per year (Excluding Owner(s)):
Gross Sales per year:
Any exposure in Other States:
What States:
List any and all autos to be quoted (Year, Make ,Model, VIN):
Location address:
Construction: (Block, Frame etc.):
Alarms/Sprinklers:
Distance to nearest Fire Hydrant:
Date Built:
Age of electrical wiring:
Square Footage:
Number of Stories:
Years at this location:

Values

Building:		Content:
Loss of Income:		Signs:
Inland Marine:		Spoilage:
Computers:		Glass:
System Protector: