Office and Business Owner Insurance Quote

Quote Request

Complete the following information if you would like to obtain a quote. Please understand this is not an application. An application will be sent to you if coverage is desired.

All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.

Personal Information

*First Name
*Last Name
Business Name
*Street Address
City/St/Zip
*Phone Number
Alternate Number
*Email Address

Underwriting Information

What is the nature of your business?
Is the business a corporation, partnership, or sole proprietorship?  Corporation Partnership Sole Proprietorship
Number of Owners
Number of Employees
Payroll of Owners
Payroll of Employees
Total annual gross receipts
Business License Number
License Type
Years of experience
Years operated under current name
Other business names?  Yes No
  If yes, what other names?
Is this business open 24 hours a day?  Yes No
Any deep frying (food)?  Yes No
Is there any manufacturing, mixing, re-labeling or repackaging of products?  Yes No
Is there filling of propane tanks?  Yes No
Please describe ANY unusual exposures:

Building and Property Information

Total square footage of the building your business is in
Total square footage of your business only
Total square footage of the customer area only
How many stories is it?
  If two stories, what is the ground floor square footage?
What is the construction type?
What type of roof covering?
Was the roof updated?  Yes No
  If yes, what year?
What is the distance to fire protection?
Is the business in a brush area?  Yes No
Do you have a storage area more than 1500 sq. ft?  Yes No
Are there smoke detectors at this location?  Yes No
Are there fire extinguishers?  Yes No
Are there deadbolts on all doors?  Yes No
Are there circuit breakers?  Yes No
Is the electrical updated?  Yes No
Is the heating / air conditioning thermostatically controlled?  Yes No
Is the heating/ air conditioning central?  Yes No
Has the plumbing been updated?  Yes No
  If yes, what year was the plumbing updated?
Does the building have interior automatic fire sprinklers?  Yes No
Is there a theft alarm?  Yes No
Is there a fire alarm?  Yes No
Are there any restaurants in your building?  Yes No
Are there any restaurants in the building next to your business?  Yes No

Claims Information

Were there any losses or claims in the last 5 years?  Yes No
  If yes, what is the date, amount paid and description of each loss or claim?

Coverage Information

Current Insurance Company
How much are you paying now?
What is the liability limit requested?
What is the building limit requested?
What is the building deductible requested?
What is the business personal property (contents) limit requested?
What is the contents deductible requested?
What is the loss of income requested?
Questions or Comments
Best Time To Contact You
Please let us know the best time to call and discuss your quote  Morning Afternoon Evening Anytime Or Specify Other:
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