Business Owners Insurance Premium Indication Questionnaire

Contact Information
 
Name of Business:
 
 
Principal Contact Name:
 
 
Street Address:
 
 
Mailing Address:
 
 
City:
State:
  
Zip:
 
Phone:
Fax:
 
Email Address:
         

Business Activities
 
Type of Business:
Sole Proprietor    S-Corp     LLC     Other
Other:
  
 
Description of Business/Services:
          
 
Date Business Established:
/ / (mm/dd/yyyy)
          
 
Annual Gross Receipts:
         
 
Have you had any losses
in the past 5 years?
Yes     No
          
 
If yes:
Date:
/ / (mm/dd/yyyy)
Amount Paid:
 
   
Details:
        

Property Information
Year Building Was Built:
Number of Stories:
Total Square Footage of Building:
Does this Business Own the Building?
Yes     No
Square Feet Occupied
by Your Business:
Sprinklers in Building?
Yes     No
Is the Building Alarmed?
Yes     No
Type of Construction:
Frame     Masonry     Metal

Coverage Information
Previous Carrier:
Expiration Date:
/ / (mm/dd/yyyy)
Premium:
Business Personal Property
Limit Requested:
Liability Limit Requested:
Building Limit Requested (if owner):
Wokers Compensation
Insurance Requested?
Yes     No

Signature
 

IT IS AGREED THAT THIS FORM SHALL BE THE BASIS OF THE CONTRACT SHOULD A POLICY BE ISSUED IT WILL ATTACH TO THE POLICY.
I understand that the final premium will be rounded to the next dollar. I declare that the information submitted herein is true to the best of my knowledge and becomes a part of my Professional Liability application.
 

The Electronic Signature Process (E-signature) provides you with a faster and more convenient way to process your application. Filling out this text box is the equivalent of signing your name.
 
E-Signature
(Please type your name)