Name of Business
Type of Business
Contact Name
Phone Number
Physical Street Address, City, State and Zip Code
Web address. If you do not have a website, state NONE:
Email Address
Years in business under similiar name?
Do you currently have insurance for your business? Yes No
Type of business formation Please Select Sole Proprietor LLC Partnership Corporation
Tax ID#
Regarding your building location(s), are you the: Owner Tenant Both
If yes, please provide the details of your current coverage. Please provide the name of the carrier, type of coverage, limits, deductibles, expiring premium and renewal date. If none, state NONE.
Regarding Property Insurance, how much in limits for the Building are you seeking?
How much insurance are you requesting to cover your equipment? If none, state NONE.
What is the usable square footage of your business?
What percentage of the premises does this business occupy?
What year was the building built?
Construction type of the building: Please Select Frame Brick Masonry Hardi Plank Fire Resistant Other
# of stores, not including basement
Foundation: Please Select Basement (Not finished) Basement (Partially finished) Basement (Fully finished) Slab Closed with crawl space Open – Height more than 2 feet Open – Height less than 2 feet Wood Other
What material is the roof made of?
Primary Heating Method: Please Select Furnace (Gase or Electric) Electric Baseboard Heat Pump Coal Furnace Steam Woodburner Above ground tank Below ground tank
How much Personal Property limits are you seeking? (including business alterations)
How high of a deductible are you willing to accept for Property Insurance?
Is there a boiler on your premises? Yes No
Do you have a smoke alarm in the building? Yes No
What type of smoke alarm? Please Select Linked to the fire department Neither
What type oif fire protection is on the premises? Please Select Sprinklers Standpipes CO2/Chemical Systems
Do you have a burglar alarm in the building? Yes No
Please advise the most recent year updates were made to the following: Roof: Electrical System: Plumbing System: HVAC System:
Do you use high power lighting for Photo or Video work? Yes No Not applicable
Do you use any toxic or flammable materials in your business? Yes No Not applicable
Is the computer equipment protected by fire protection & suppression device? Yes No Not applicable
How often do you back up all computer data? Daily Weekly Monthly Quarterly No backup necessary
Is back up stored off premises? Yes No Not applicable
If yes, provide details. If this does not apply, state N/A.
Is computer equipment & media located above ground level?
Please state the annual gross billings for the most recent 12 month period:
How many employees do you employ? Full Time: Part Time:
What is your gross annual payroll?
Please provide a breakdown of your annual payroll by department. (i.e.: office, salespeople, laborers, drivers, etc.)
Do you have any operations other than the business operations described? Yes No
If so, please describe below:
Do you have any other additional locations? Yes No
If yes, please provide the location address, Building Limits and Personal Property Limits:
Would you like the vehicles used in your business to be covered under the same policy, if possible? Yes No
If yes, please provide the following information: Year: Make: Model: Cost New: VIN# (17 digits) Garaged/Parked Location Zip Code
Please provide the following driver information: Name: Date of Birth: License Number: State licensed:
Have you have any claims the last 5 years? Yes No
If yes, please provide details and how much money was incurred by the carrier:
Would you like a quote for Umbrella Insurance? Yes No
If yes, how high of a limit in excess of the primary insurance limit are you seeking? $1,000,000 $2,000,000 $3,000,000 $4,000,000 $5,000,000 more than $5,000,000 excess of the primary insurance
Would you like a quick quote for Employment Practices Liability? Yes No
Did we miss something? Additional Comments:
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