Business Commercial Phone General Information Contact Name Address City Zip Code Phone Email Business Information Type of Business Years in Business Number of Employees Do You Lease Employees? Yes No Do You Use Any Sub-Contractors? Yes No Is Your Business: Sole Proprietor Partnership Corporation If Corporation or Partnership: Number of Officers Previous Insurance Information Federal Identification Number Ever Cancelled or Non-Renewed? Yes No N/A Do you have a State/County/City Occupational License Yes No Income Information Payroll Employees Secretarial Self Other Revenue/Income: Current Year Revenue/Income: Last Year Limit of Liability Desired Liability $300,000 $500,000 $1,000,000 Other Medical Desired $5,000 $10,000 Other Deductible $0 $250 Other Other Info Equipment / Tool Coverage Desired? Yes No Is your Business Office in your Home? Yes No Do you have a separate Garage or Storage Unit for your Business? Yes No Do you own/rent an office location? Yes No Building/Business Furniture Coverage Desired? Yes No Year Built Total Square Footage # of Stories Length/Width Construction Type: Concrete Block Frame Brick Veneer Other Burglar Alarm Yes No Fire / Smoke Alarm Yes No Dead Bolt Locks Yes No Fire Extinguishers Yes No Sprinklers Yes No Inside City Limits Yes No Distance to Fire Hydrant Fire Department List ALL Claims or Losses Paid or NOT I understand that I am requesting an Insurance Proposal based on the information I am providing. I am requesting the Limits and Coverage as indicated. All information is true and accurate to the best of my knowledge. I do understand that this is an estimate and the premium could change based on reports and additional information obtained by the insurance carrier. I give permission to check all public information available as necessary to provide a Proposal. I understand that I am requesting an Insurance Proposal based on the information I am providing. I am requesting the Limits and Coverage as indicated. All information is true and accurate to the best of my knowledge. I do understand that this is an estimate and the premium could change based on reports and additional information obtained by the insurance carrier. I give permission to check all public information available as necessary to provide a Proposal . *
