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Businessowners Quote
Company Name:
Contact Person:
Address:
City/State/Zip:
E-Mail:
Telephone:
FAX:
Current Insurance Information
Insurance Company Name:
Premium Amount:
Policy Exp. Date
List and describe any losses in the past 3 years
What does your business do.......
Please Describe Your Business
Legal Structure:
Years In Business:
Annual Sales or Rents:
Payroll:
# of Full-Time Emp
# of Part Time Emp
Are You the Building Owner
Number of Locations
or the Tenant
Please answer the following questions for each owned property. If you are the tenant you need only to list the contents.
Location #1
Building Address ( Street/City/State and Fire Protection Class, if known)
Building Limit Requested
Construction Type
Square Footage
Contents Limit Requested
Age
Location #2
Location #3
Location #4
Location #5
Additional Information/Comments
Please Note: To offer you accurate quotes, insurance companies may collect information from consumer reporting agencies, such as driving record, claims, or credit history reports.