Business Information:

Proprietor's Name:  

Email:  

Legal Name of Business:  

Business Address:

Phone: Fax:# Locations:# Employees:

Please describe your business:

# of years in business:If less than three years, then how many years of experience does the proprietor have in this field?:

Please Check:    Sole Proprietor    Partnership     Corporation     Does the Proprietor own or operate any other business:  If so, please state:

Current Insurance Company:

When does your present insurance expire? (Month/Day/Year)

Business Coverage:     Workers' Compensation: Commercial Auto:

Describe all losses within the past three years, whether reimbursed or not, including the date and the amount of loss:

Has your insurance ever been canceled or not renewed:  If so, for what reason?

Business Information:

Street, City, State, County, Zip:

Area (Sq. Ft.):# of units (If Apartment):Year Built:    (If over 30 years old, was the following updated?  If so, when?)  Wiring:     Heating:     Plumbing:

# Stories:Building Value (If Owned):Value equip/furn, etc.

Deductible:    $250    $500     $1,000    $2,000    $2,500

Annual Payroll:    Annual Sales (to nearest $1,000): If business is optical goods, hearing aids or drug store, what is the percentage of professional sales to annual sales?%

Construction Type   (Please check appropriate boxes)

Exterior Walls:    wood, stucco or brick veneer     metal panels    masonry (brick, concrete block, stone)    fireproofed walls

Roof:    wood    metal panels    noncombustible material    reinforced concrete

Is the building Sprinklered?Is there a swimming pool on location?Is there a fire/burglar alarm?If so, what type?    central station    police department    local

Coverage Information:

I would like a no-obligation quote for the following business package coverages:

Business Liability    Building     Business Personal Property     Business Income Interruption    Equipment Breakdown

The following additional coverages are available. Higher limits are available upon request.

YES.  I would like these coverages included in my quote (check all that apply)

Computers and Media $10,000     Accounts Receivable $25,000     Valuable Papers $25,000              Property in Transit $15,000    Personal Property of Others $10,000    Employee Dishonesty $10,000    Temperature Change $10,000    Forgery or Alteration $10,000    Backup of Sewer or Drains $25,000    Personal Effects $2,500

Call to find out about our coverages available for the following:

(1) Workers' Compensation

(2) Commercial Auto Liability and Physical Damage

(3) Employment Practices Liability

(4) Commercial Umbrella

(5) Flood Insurance

Specific features and credits may vary and may not be available in all states.  Applicants are individually underwritten and some businesses may not qualify.