Name of Insured:

E-MAIL Address:

Type of Entity:
Individual   Partnership   Corporation   LLC

Name of Owners/Officers:

How long have you been in business?

If less than three years, how long have you been doing
this type of work?

What kind of products do you sell? Be as specific and detailed as possible
and include whether you are a retail, wholesale, or restaurant operation.
For example, "retail candy store," or "wholesale auto parts." For restaurants,
describe the type of food sold and seating capacity.

How many employees do you have in addition to the owners?

What is your expected annual payroll to
employees other than the owners (total for all employees)?

What would you expect your gross sales to be for the next 12 months?

Do you sell alcohol?  Yes   No
If "Yes," what would you expect your annual alcohol sales to be?

Describe the construction of the building that you occupy:
 Frame
 Brick
 Brick w/concrete and steel roof and floors

How far is it to the nearest fire hydrant?
 under 1000 feet
 over 1000 feet
 none in sight

How far is it to the nearest fire department?

What limit of coverage do you want for general liability?
 $300,000
 $500,000
 $1,000,000
 $2,000,000
 More

Do you want work comp coverage?  Yes   No
If "Yes," do the officers/owners wish to be covered?  Yes   No

Do you have an experience modification factor for work comp?
 Yes   No   Don't Know
If "Yes," what is it?

How much coverage do you want for your business property,
including inventory, furniture and fixtures, and tenants
improvements and betterments?

Do you want coverage for any buildings used in business?
Keep in mind that normal homeowners policies exclude other
structures used in whole or in part for business.  Yes   No
If "Yes," how much coverage?

Do you currently have business insurance?  Yes   No
If "Yes," through what companies and expiration date?

If you have had any claims in the last three years,
please provide the details:

Please provide a name and phone number where we can
contact you to send you the quote:
Name:
Voice Phone Number:
Fax Number:

Please add any remarks or additional information
that you think is important for us to provide a quote.