BUSINESS INSURANCE

QUOTE FORM

 

 

Name of Owner: ______________________________________________

 

Home Address:________________________________________________

 

Name of Business:______________________________________________

 

Business Address:______________________________________________

 

 

How many years in Business_____Corporation / Partnership / Individual

 

 

Owners S/S #_____________Fed Tax#____________State Tax#________

 

 

Owners Date of Birth___________Type of Business_________________

 

 

How many employees_______Estamted Annual Payroll______________

 

 

Estimated Gross Sales____________Contractors Lic#________________

 

 

Age of Building_____Sprinklers Yes /No Alarm Yes /No Central Yes /No

 

 

Previous Insurance Company_________________# of Claims_________

 

 

Hm Phone #____________Wk Phone #____________Fax #___________

 

*Additional Information for Workers Compensation 3 years of loss runs:

Owners / Officers

Include Name  /  Date of Birth  /  Title  /  % of Ownership  /  Salary