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On-Line
Business
Insurance Quote Form
One Simple Form - takes only 2-3 Minutes!
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| Your Personal Data |
| Your Name: |
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| Your Company's Name: |
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| Street Address: |
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| City: |
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| State: |
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| Zip/Postal: |
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| E-Mail (REQUIRED): |
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| Phone: |
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| Fax (optional): |
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Currently Insured?
(If yes, list carrier, and # of years continuous.
If none, type NONE) |
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List Claims
& Amounts Paid
(If none,
type NONE) |
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| Years In Business: |
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Business type:
(proprietorship,
corporation, etc.) |
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| Underwriting Information: |
| Describe IN DETAIL, Your Business
Operations: |
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| Ownership & Payroll
Data: |
| List Employee's Annual Payroll Here:
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$ |
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| Insert # of Employees here:
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| Location & Sales
Information: |
Insert Annual Gross Revenues from
this
operation here:
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$ |
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| Square Footage of office or business
location: |
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| Type of Building (wood frame, concrete,
etc.): |
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| Number of Stories: |
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| Are there other business/residence
in this building(describe)?: |
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| Describe safety features(alarm, sprinklers,
fireprotection, etc): |
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| Coverage Desired:
(Check One Please) |
| The Coverage I Am
Looking For: |
| Coverage |
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Liability Only |
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Liability & Business Contents |
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Liability, Building & Contents |
A Package Policy Including the Above,Plus
Miscellaneous
Coverages |
NOTE: Don't worry if you are not exactly
sure about coverage type... we will suggest the best coverage
for you - just try to tell us what you are looking for!
(If we need more info. we will let you know.)
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Liability Coverage:
($300,000, $500,000, $1 Million, etc.) |
$ |
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Business Contents Coverage:
(The amount of your personal business
property) |
$ |
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Building Coverage:
(The amount of building coverage if you
own your bldg.) |
$ |
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Miscellaneous Coverage:
(List any special coverage peculiar to your business, such as
Garagekeepers Legal,Loss of Earnings, Valuable Papers, etc.)
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$ |
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| Send my quotation
via: |
| We will have
your quote to you within 24 hours. If all information is present
we will send by email, otherwise an agent might need to contact
you to ensure you are getting all discounts necessary. |
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Thank you for filling out this form COMPLETELY!
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We value your input as PRIVATE information.
Every step has been taken to insure your privacy, security,
and our intent is to release quote information only to you.
We will not give your data to ANY other person or group
for sales, marketing, or ANY other purposes. By checking
the box below you agree to allow our agency to release this
information via the method you have chosen, and to release
us from any liability should this information be accidentally
viewed by others. Our intention is to maintain your complete
privacy.
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Click Button Below When Done
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Please Click Only Once . . . May take up to
30 seconds!
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