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Company Name:
Contact Name:
Phone #:
Email Address:

Brief description of operations
Year business started:



Property
Address 1:
Address 2:
Deductible $:
Any claim last three years?

 

Building #1
Year built:
If over 25 years old (Updates):
Square Footage:
Type of construction:
Amount of coverage on structure $:
Amount of coverage on contents $:

Building #2
Year built:
If over 25 years old (Updates):
Square Footage:
Type of construction:
Amount of coverage on structure $:
Amount of coverage on content $:


Liability

Limits

General aggregate $:
Products and completed operations $:
Per occurrence $:
Personal advertising/injury $:
Fire legal damage $:
Medical payment to others $:

Additional Information for Quoting

 

Annual sales (gross) $:
Total # of employees:
# of Full-Time (excl owners):
# of Part-Time:
# of Owners:
Payroll minus owners $:
Any claims last three years?

 

Workers Compensation
Liability Limits:
Federal I.D. #:
Experience modification:
Any claims last three years?
Class/Payroll:
class
 		payroll

Excluded from W/C

name position

Business Auto

Year Make Model Vin# Comp. Coll. O.C.N. G.V.W Use?

Liability Limits               Medical Payments Limits
Driver Info

Name D.O.B. N.C.D.L. #
Any Claims last three years?

 

Commercial Application