Business Owner's Package Insurance Quote General Information Property Questions If The Building Is Over 25 Years Old, Please Answer The Following Protective Devices Liability Questions Coverage Limits Miscellaneous Information Additional Comments Name of Insured Address City State Zip Code Business Phone Fax Number Email Address Location Address (type "same" if same as above) City State Zip Code Proceed Age of building /Year Built Type of building construction FrameStuccoMasonry / BrickFire ResistiveOther Number of Stories Other Occupancies Square Footage You Occupy Back Proceed Year electricity was updated is it on circuit breakers? Yes No Year plumbing was updated Type of plumbing Copper Galvanized Other Year building was last re-roofed Type of roofing material Type of heating system in building Back Proceed Burglar Alarm Yes No Alarm Type Central Station Local Alarm Name of Alarm Company Is the building sprinklered Yes No Are there smoke detectors? Yes No Back Proceed Previous Insurance Carrier Policy Number Prior premium $ Policy renewal date Years in business Projected gross annual receipts ($) Projected annual payroll ($) Describe your business, product or service Back Proceed Building $ Contents (equipment, inventory, supplies, etc) $ Actual Cash Value or Replacement Cost: ACV Replacement Cost Deductible $100$250$500$1000 Loss of Income $ Money and Securities $ Glass or Signs $ General Liability Limit $100,000$500,000$1,000,00$2,000,00 Non-owned and Hired Automobile Liability Is liquor liability needed? Yes No If Glass Coverage is needed, please provide dimensions Please list other coverages you may need Back Proceed Name of Additional Insured (Landlord or vendor) Mailing Address City State Zip Back Proceed Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough fields above, please enter them here. Back Send
