Filling out these forms will assist us in expediting the quoting process and provide you with the best possible insurance programs at the best prices available in the insurance market place.

DETAILED DESCRIPTION OF OPERATIONS:

PLEASE COMPLETE ONLY THE APPLICABLE QUESTIONS:

Property (each location)

Building address:

Construction of building:

Year built:

If over 25 years, list the year of updates:

How many stories:

Fire sprinklers? Yes No

Burglar alarm? Yes No

Square footage:

Estimated value of building (if owner): $

Amount of business personal property: $

Automobile (each auto)

Year:

Make:

Model:

Estimated value:

VIN#:

Gross vehicle weight (if heavy vehicle):

Comprehensive deductible: $

Collision deductible: $

Driver List (each driver)

Name:

Date of birth: (DD-MM-YYYY)

License #:

License state:

Any accidents/violations: Yes No

Workers Compensation

Type of work done by employees:

Do you use any independent/sub contractors? Yes

Do any employees travel out of state?

Number of employees:

Information for EACH officer/owner

Name:

Date of Birth: (DD-MM-YYYY)

Title:

% ownership:

Duties:

Estimated annual payroll: $

(apply payroll cap of $36,000 for any one employee)

Are you interested in a umbrella quotation? Yes

List any other pertinent information, questions or concerns: