SECTION I - GENERAL INFORMATION

Legal Business Name
Contact Person
Mailing Address
Phone Business Fax #
Years In Business
Federal Tax Identification #
Type of Business

SECTION II - PROPERTY INFORMATION

Location Address
Construction of Building
Age of Building
Square Footage of Your Premises
Occupancy of Building
Number of Stories of Building
Sprinkled Building Yes No

Property Values		Deductible (select one)
Building	$	250 500 1,000
Contents	$	250 500 1,000
Inventory	$	250 500 1,000
Sign	$	250 500 1,000
Computer	$	250 500 1,000

SECTION III - GENERAL LIABILITY INFORMATION

Description of Your Business
Estimated Annual Sales $
Estimated Annual Payroll $ Number of Employees
Select the Limit of Liability You Desire 300,000 500,000 1,000,000
Umbrella Liability Limits  1,000,000 3,000,000 5,000,000

SECTION IV - BUSINESS AUTO INFORMATION

Liability Limit	300,000	500,000	1,000,000
Medical Payments	1,000	2,000	5,000
Uninsured Motorist	300,000	500,000	1,000,000
Comprehensive Deductible	100	250	500
Collision Deductible	250	500	1,000

DRIVER LIST

Full Name	Date of Birth	Drivers License #
1
2
3
4
5

VEHICLE LIST

Year	Make	Model	G.V.W.	Cost New	Garage Location
1
2
3
4
5

SECTION V - WORKERS COMPENSATION INFORMATION

Are owners, partners/officers to be covered by Workers Comp? YesNo
List them below:

SECTION VI - OPTIONAL COVERAGES

	OPTIONAL COVERAGES	LIMIT
YesNo	Loss of Income Coverage	$
YesNo	Glass Coverage Linear Feet	$
YesNo	Property of Others	$
YesNo	Employees Practices Liability	$
YesNo	Garagekeepers Coverage	$
YesNo	Contractors Equipment	$

Please list below any unique coverages or exposures that are not listed on this quote form:

Answer all of the above questions, then send form.-->