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Business Quote

Contact Information
Date: Need By (Date):
Expiration date: Need original for closing? Yes No
Contact Name: Contact Email:
For inspection:      
Mobile #: Work #:
Home #: Fax #:
Business Information
Name of Business: Business Address:
Business City: Business State:
Business County:    
Business Owner's Name / Title: Owner is an / a:
How many years in Business: Working for: Self Others
Type of Business: Retail: Wholesale:      Both:
Construction: Condition:
Year Built: Year Gutted:
What type of product's do you sell? What are your store hours?
General condition of business?    
Exposure left: Ft. Exposure right: Ft.
Exposures in building: Do you live in the Building? Yes No
Any apartments in building? Yes No If yes, how many?
Your total annual gross receipts: Number of employees: Full time: Part time:
Do you need worker's comp? Yes No Total annual employee payroll:
Total annual officer payroll (if inc.):    
Floor is the business located on: Basement  1st 2nd Other If other, please specify:
Do you have in your possession property of others? Yes No If so, how much?
Any loss payees/additl. insured's? Yes No Money and Securities:
Does Building have any alarms? Smoke: Central Burglary: Central Fire: Local Gong:
Does Building have Sprinklers?  Yes No Totally sprinklered? Yes   No
Measurements of the building: x How many floors?
Updates? When (date): Roof : Electric: Plumbing: Heating:
Vacancies in the building?  Yes No Graffiti on the building?  Yes No
Vacant buildings on block?  Yes No If yes where?
Heating System: If Oil?
EPA Certified Tank? Yes No Condition:
Oil Tank Above Ground on: Oil Tank age (If in ground):
Insurance Information
Fire Insurance on contents? Fire Insurance on building?
Deductible: Robbery & Burglary Insurance? Yes No
Need Glass Insurance?  Yes No If yes, measurements?   Linear Feet:
How much liability needed? Umbrella amount in Millions:
Need Stock Spoilage Insurance? Yes No If yes, how much?
Any additional insured's? Yes No If yes, names?
Need Flood insurance? Yes No Distance to water:
Account Receivable / Valuable Paper coverage? Yes No Need Employee Dishonesty coverage? Yes No
Need Boiler & Machinery Insurance? Yes No Need Computer coverage? Yes No
Value of Computer Hardware: Value of Computer Software:
Additional Information
Own other property/businesses? Yes No Do you need them quoted? Yes No
What company insures you now? Current premium:
Why do you want to switch? Pricing: Switch Agent: Being Cancelled: Cancelled:
Been cancelled in last 3 years? Yes No If yes, why?
Losses in the past 3 years? Yes No If yes, type of Loss:
If yes, date of Loss: If yes, amount of Loss:
Do you make deliveries? Need commercial auto coverage? Yes No
Referred by: Other:
Notes:
       
     

Reproduction of this Questionnaire is restricted unless permission is given.

 
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