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PROPERTY & GENERAL LIABILITY QUOTE

Simply fill out the information below as thoroughly as possible and submit your application. It will be sent to us, in confidence, and we will process your information and contact you shortly with your quote.

Business Information

Business Name: Email Address:
Contact Name: Phone:
Address:
County: 		Fax:
City:  State:   Zip: Best Time To Call:  
Number Full-Time Employees Describe the Nature of Business:
Number Part-Time Employees
Years in Business:
Number of Owners
Total Annual Payroll: $
Total Annual Gross Receipts: $
How did you hear about us?
If "Friend/Co-Worker", please give name:
If "Other", please explain:
How would you like to receive your quote?

Current Property/General Liability Insurance Information

Company Name (not agency): Years insured:
Policy Expiration Date: Premium Amount: $
Amount Insured For: $
Term: If Other:
Prior Losses in last 3 years (include description, date & amount):

Coverage

Building Limit:
Contents Replacement Value:
Liability Limit (Occurrence/Aggregate):
Property Deductible:
Type of Coverage desired:
If "Other" Coverage, please explain:

Construction

Exterior: Roof:
Age of building: Age of roof:
Square footage of your business area?
Stories in building:
Square footage of the entire building? Updated Heating or Plumbing?

Within 1000 feet of a fire hydrant?
Within 5 miles of a fire station?
Central station Burglar Alarm?
Automatic sprinkler system covering 100% of your premises?

Additional Comments

Please give any additional comments you feel appropriate for this quotation. If you have additional locations, please enter as much information as you can here.


One of our representatives will respond to your submission as soon as possible.



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