Pier & Post Other
(list in remarks)
Tar/Gravel Spanish Tile
Number of stories:
Do you own animals or pets?
If yes, list type/for dogs, list breed:
Are You Near Brush Area?
# of feet to nearest fire hydrant:
# of miles to nearest fire station:
Name of Carrier & how long insured?
Describe claims in detail:
Circuit Breakers or fuses?
Ownership & Payroll Data:
List Employee's Annual Payroll Here (if none, enter $0):
Insert # of Employees here:
Location & Sales Information:
Insert Annual Gross Revenues from this operation here:
Square Footage of office or business location:
Type of Building (wood frame, concrete, etc.):
Number of Stories:
Are there other business/residences in this building (describe)?:
Describe safety features (alarm, sprinklers, fire protection, etc):
Coverage Desired: (Check One Please)
The Coverage I Am Looking For:
Liability & Business Contents
Liability, Building & Contents Coverage
A Package Policy Including the Above, Plus Miscellaneous Coverages
NOTE: Don't worry if you are not exactly sure about
coverage type... we will suggest the best coverage for you - just try to tell us what you are looking for! (If we need more info. we will let you know.)
Business Contents Coverage: (The amount of your personal business property)
Building Coverage: (The amount of building coverage if you own your bldg.)
Miscellaneous Coverage: (List any special coverage peculiar to your business, such as Garagekeepers Legal, Loss of Earnings, Valuable Papers, etc.)
Farmowner Underwriting Information:
How Many Acres?
What Variety(s) of Trees?
Yearly Income from Growing Operations $
Number of Workers on Site:
Send my quotation via:
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