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Fields marked (*) are mandatory.
Agent Name*
Agent Number*
Agent PH #*
Agent Fax #
Name of Business*
Name of Owner*
Type of Entity*
Federal Tax I.D. # or Social Security # ?
Phone #*
Fax #
Description/Nature of Business?*
How many years in business?
OR - How much expeience in this field?
Annual Payroll*
Annual Gross Receipts/Sales*
How many Full Time employees?*
How many Part Time employees?*
How much contents coverage needed?
This form is for indication ONLY
To obtain a full quotation, we will require the following:
Copy of existing policy declarations page required
Claims/Loss History (5 years) with Insurance Company Loss Runs
All items marked * must be answered to recieved a response!
What deductibles do you prefer?
Type of Contents
How much square footage does your business occoupy?*
Total building square footage*
Is Bldg sprinklered?
Year Bldg built?*
Construction Type?*
If other please describe
If building owned, how much coverage required?
What limits of liability?*
Limit if other
Any losses?*