Business Name *
Name *
Last Name
E-Mail *
Best Phone To Reach You *
How Long Have You Been In Business?
How Many Employees Do You Have?
What Kind of Assets Do You Want To Protect?
Vehicle Insurance - Fleet
Building and or Machine Equipment
Errors / Omissions
Major Medical for Employees
Supplemental Insurance for Employees
Farm Vehicles
Other:
General Liability Claim
Limits
100-300
300-600
500-1 Mil
1 Mil - 2 Mil
# of Owners
Anual Sales/Receipts
Payroll Excluding Owner
Sub-Contracted Costs
Property 1
Location 1
Year Built
Square Footage
Use of Building
Updates Electric
Plumbing
Heating
Roofing
If older than 20 years:
Value $
Deductible $
Contents $
Construction type:
Frame
Non-Combustable
Masonry Non-Combustable
Modified Fire Resistive
Fire Resistive
Other?
Sprinklered?YesNo
Location 2
Construction Type:
SprinkleredYesNo
Inland Marine/Contractors Equipment
Equipment Over $1000 Gross Amount
Under $1000 Gross Amount:
Deductible:
Worker’s Compensation
Type of Work
Class Code:
Payroll Figures
Owners:
Included
Excluded
FEIN#
EMod
Auto
Liability Limits
$80
$100
$250
$300
$500
$750
$1 Mill
Year
Make
Model
VIN#
Full Coverage
Liability Only
Comp Ded
Collision Ded
Towing
Rental/Limit
Drivers
Name
DOB
DL#
# Tickets/Accidents in Last 3 Years
Builders Risk
Completed Value of Building $
Deductible
How Long Until Completed
% Already Completed
2 + 5 = ?Please prove that you are human by solving the equation *
