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Quote Commercial Insurance

Client Information:
Owner's Name :
Business Name :
Telephone : Fax : Email :
Business Address :
Type of Ownership : Indivisual Partnership Corporation Other
Description of your business :
New Venture? : Yes No
If Yes, Number of past experience : years
If No, How many years at present location : years
Current Insurance Company :
Current Insurance Policy No : Expire date :
Loss History : Yes No
If yes , Explain
How much do you want to have General Liability Coverage
$500,000 $1,000,000 $2,000,000 Other $
Annual Gross sale : $
Annual Payroll : $
Do you need Liquor Liability? : Yes No
Want to have Building coverage? Yes No If yes, How much : $
Want to have Contents coverage? Yes No If yes, How much : $
Do you need Theft coverage? : Yes No
Year built of the building ? : , Remodeling year ? :
Number of stories ?: , Total area of store ?: S/F, Customer area ?: S/F
How many days open : days a week, Business Open Hour : From To
Have a Sprinkler ? : Yes No
Have an Alarm ? : Yes No If yes , Alarm Company name :
Tell me who is your right side :
Left side :
Rear side :
Landlord or Loss Payee required insurance ? : Yes No
If yes, name :
address :
Do you need workers compensation coverage? : Yes No
Memo