ONLINE BUSINESS QUOTE FORM


Name of the Business

Applicant Name

Address
City, State, Zip
County
Home Phone - -
Work - -
Fax - -
E-Mail
Federal TAX ID #
Social Security # - -
Type of Business
Years In Business

 

NATURE OF BUSINESS

Option which best describes your business:
Number of employees
Hours of Operation
Description of Operations and Occupancy:

 

PREMISES  

Address
City, State, Zip
County
Click if primary premises
Your Interest:
Square Feet
Area Occupied (percentage)
Year Built  
Surrounding Exposures & Other Occupancies :

 

REAL PROPERTY

BLDG.
LIMIT $ VALUATION:
Deductible Sq. Feet
Construction Type Stories
Sprinklers Wiring (year)
Basement Present Yes   No Basement Finished?
Roofing (year) Plumbing (year)
Heating (year) # Apt. Units
Roof Material

 

PERSONAL PROPERTY

LIMIT $ VALUATION: Deductible

 

LIABILITY (Choose the limit options compatible with the program you are requesting)

Produits/Comple Operation liability
Medical Expense (per person)
Fire Damage Leal liability
General Aggregate Liability
Personal/AD. Injary liability 

 

ADDITIONAL COVERAGE

Coverage Amount Deductible
Extra Expense $ $
Loss Of Income $ $
Valuable Papers $ $
Accounts Receivable $ $
Sign $ $
Employee Dishon $ $
Burglary Stock $ $
Burglary Money $ $
B & M Broad $ $

Coverage Amount Deductible
Money & Securities $ $
Spoilage $ $
Business Computers $ $
Ord or Law $ $
Erisa $ $
Flood $ $
Earthquake $ $
B & M Basic $ $
B & M Spoilage $ $

Glass
Location In Bldg. # Panes W x H Length Linear FT Glass Type Value Deductible
Ground Floor Glass $ $
Above Ground Floor $ $
Is there a heating broiler?

 

GENERAL INFORMATION

Please explain all "YES" responses

Yes

No

Describe any location/business interest owned by injured but not listed

Do you have past, present or discontinued operations involve(d) storing, treating, discharging, applying, disposing or transporting hazardous material?

    
Are Athletic Teams Sponsored?
Are certificates of insurance required from sub contractors? If so, who checks them?
During the last ten years, has any applicant been convicted of any degree of the crime of arson?
Annual Sales/Receipts   $ Total Payroll $

 

SPECIALTY PROGRAMS

Apartments and Condominiums
Are there any swimming pools or playgrounds?
Is aluminum wire used?
Number of units per building or fire division:
Indicate where coverage applies to: Bare Walls
Smoke Detectors:
 
Contractors
Does applicant draw plans, designs or specifications?
Do any operations include excavation, tunneling, underground work or earth moving?
Does applicant lease equipment to others with or without operators?
Restaurants
Is there an automatic fire protection system installed?
Is there an automatic fuel cut-off?
Is there a hood and duct service contract?
Contract Expiration Date:

 

CRIME

Alarm Type
Alarm Description
Safe Vault
Premises Alarm
Label : UL / SMNA / Class
Safe/Value/Receptacle/Mfg   Name

Maximum Cash on Premises $

Maximum Cash on Messenger $

Money on Premises Overnight $

Frequency of
Deposits

Deadbolt Cylinder Door Locks?      
Other Protection (lighting, fences, watchpersons, etc.)

 

PRIOR POLICY(IES)/LOSS HISTORY

Previous Carrier:
Policy Number:
Exp. Date      
# Losses Last 3 Years 
Total Losses $