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| Business Information |
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Proprietor's Name
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Business Address |
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Legal Business Name
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City |
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Email Address
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State |
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Phone Number
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Zip Code |
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Fax Number
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# of Locations
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# of Staff |
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Full-Time Part-Time |
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Form of Business
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# of Years in Business
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# of Proprietor's Years in Business |
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If Less than 3 years, Enter # of Proprietor's Years in Business in the next field
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How You Found Us
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If you found us by some other source not listed to the left, please specify below
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Does the Proprietor own or operate any other business? If so, please state.
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Previous Insurance Carrier (Company Name Only)
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Policy Number |
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When does your present insurance expire?
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Premium |
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Month Day
Year
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$ |
| Describe all losses within the past 3 years, whether reimbursed or not, including the date and amount of the loss. |
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| Has your insurance ever been cancelled or non-renewed? If so, for what reason? |
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| Location #1 (predominant building) |
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Address
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Area (square feet) |
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City
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Year Built (Please use a four digit format i.e, 1970, 2000, etc.) |
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State
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Age |
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Zip Code
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If the building is over 30 years old, enter the years the following components were updated, if they were at all |
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wiring heating plumbing |
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County
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Number of Stories |
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Business Property
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Building Value (if owned) |
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$
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$ |
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Deductible
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Annual Sales/Receipts |
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$ |
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Annual Payroll
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(If business involves Optical Goods, Hearing Aides or Pharmaceuticals, what is the percentage of Professional Sales to Annual Sales?) |
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$
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% |
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| Construction Details |
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Type of Contruction
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Exterior Walls |
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Roof Type
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Is the building sprinklered? |
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Yes No |
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Is there a fire/burglar alarm?
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If There Is a Fire/Burglar Alarm, Specify the Type |
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Yes No
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| Coverage Information |
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YES! I would like my No-Obligation Quote to include the Basic Components. The Basic Components include the following:
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Business Liability
Building and Business Personal Property
Business Income
Equipment Breakdown
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Please select other coverages you would like included in your quote below. (Check all that apply) The limits shown next to each coverage type are automatically included, unless specified otherwise. Should you require a higher limit, please fill in the appropriate amount in the space provided. Please note that you may not change limits for Forgery/Alteration, Sewer/Drain Backup and Personal Effects.
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| GENERAL LIABILITY LIMITS |
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| Please fill in the following blanks so that we may better aquaint ourselves wth your general liability needs: |
| Total Value of Scheduled Equipment |
Total Value of Unscheduled Equipment |
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$ |
| Maximum Value of Leased Equipment |
Installation Value Per Project |
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$ |
| Type of Equipment Leased |
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| COMPUTERS/MEDIA-$10,000 |
ACCOUNTS RECEIVABLE-$25,000 |
| $(If higher limit required, enter here) |
$(If higher limit required, enter here) |
| VALUABLE PAPERS-$15,000 |
PROPERTY IN TRANSIT-$15,000 |
| $(If higher limit required, enter here) |
$(If higher limit required, enter here) |
| PERSONAL PROPERTY OF OTHERS-$10,000 |
EMPLOYEE DISHONESTY-$10,000 |
| $(If higher limit required, enter here) |
$(If higher limit required, enter here) |
| TEMPERATURE CHANGE-$10,000 |
FORGERY OR ALTERATION-$10,000 |
| $(If higher limit required, enter here) |
higher limits not available
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| SEWER/DRAIN BACKUP-$25,000 |
PERSONAL EFFECTS-$2,500 |
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higher limits not available
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higher limits not available
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Indicate Any Other Requested Coverages and Amounts below
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