Business Owner's Insurance Quote Request Form

Business Name:

Address:

City:

State:

Zip Code:

Primary Contact:

Phone:

Fax:

Email:

Effective Date:

Type of Legal Entity:

Date Business Started:

# of Full Time Employees:

# of Part Time Employees:

Gross annual revenue:

Gross annual payroll:

Nature of Business:

Location Information

Year Built:

Total Square Footage:

Square Footage Occupied by You:

# of Stories:

If building is more than 15 years old, list year of improvements:

Roof:

Wiring:

Plumbing:

Heating:

OR Total Renovation Year:

Nature of other business in building if applicable:

Coverage Desired

Add the replacement cost of your office contents:

Computers:

Software:

Law Library:

Furniture:

Non-computer equipment:

Valuable papers:

Miscellaneous:

Total value of business personal property:

Any Additional Coverages Desired

Do you have any prior carriers in the past 3 years?

Yes
No

If yes, complete the following:

Carrier	Policy Number	Limits of Liability	Policy Term

Landlord information if rented (Name, Address, City, State and Zip Code):

Additional insured information if applicable (Name, Address, City, State and Zip Code):

Loss History

Date of Claim:

Type of Claim:

Amount:

Details:

In the last 3 years has any insurance company declined to issue a policy, or cancelled, or failed to renew existing coverage for the business?

Yes
No

If yes, please explain:

Questions & Comments: