You may contact me at the above number to
discuss this quote
Carrier/# of years
Yrs in business
Claims & Amounts Paid
(If none, type None)
Describe Business In Detail
(Computer repair, Computer store, etc)
Describe In Detail Your Business Operations
Ownership & Payroll Data
Employee's Annual Payroll (If none enter 0)
# of employees
Location & Sales Information
Annual Gross Revenues (If none enter 0)
Sq. ftge. of office or building being used
Other (Explain below>
Other (Explain below)
Are there other businesses/residences in this building?
Describe safety features (alarm, sprinklers, fire protection, etc.)
Please explain all other data in the space below and any other information you feel
would be pertinent to your quote.
Coverage Desired (Please select one)
Liability & Business
Liability, Business & Contents
A Package Policy
including the above plus
NOTE: Don't worry if you are not sure about coverage type. We will
suggest the best coverage for you. Tell us what you are looking
for. If additional information is needed we will contact you.
($300,000, $500,000, $1 Million, etc)
Business Contents Coverage
(Amount of business property)
(Amount of building coverage if owned)
(List any special coverage peculiar to your business, such as
Garagekeepers Legal, Loss of Earnings, Valuable Papers, etc)
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