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Comm'l Acct Questionaire
For Help Call 979-793-5060
Fields marked (
*
) are mandatory.
Agent Name
*
Agent Number
*
Agent PH #
*
Agent Fax #
Name of Business
*
Name of Owner
*
Type of Entity
*
Corporation
Individual
Other
Partnership
Federal Tax I.D. # or Social Security # ?
Address
*
Phone #
*
Fax #
E-Mail
*
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
Remarks
All items marked * must be answered to recieved a response!
What deductibles do you prefer?
1000
10000
2500
500
5000
Type of Contents
Business Pers. Prop.
EDP-Media or Hardware Fine Art
How much square footage does your business occoupy?
*
Total building square footage
*
Is Bldg sprinklered?
No
Yes
Alarm?
Central Station
Local Gong
Year Bldg built?
*
Construction Type?
*
Frame/Stucco
Joisted Masonry
Other
If other please describe
If building owned, how much coverage required?
What limits of liability?
*
$1,000,000
$2,000,000
$500,000
Other
Limit if other
Any losses?
*
No
Yes