Quotation Form
SMALL BUSINESS INSURANCE QUOTATION FORM
To help us supply you with the most accurate quote possible, please answer as many questions
as you can with the most accurate information available to you.
Information submitted will be held confidential and will be used for quote purposes only. Submission
of application information in no way obligates you to purchase any product or insurance, nor does it represent any agreement to provide coverage under any insurance policy.
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BUSINESS
INFORMATION
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Your name:
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First:
Last:
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Name of business:
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E-Mail address:
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Address:
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City:
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State:
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Zip code:
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Years in business:
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Policy period:
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Phone numbers:
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Daytime:
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Evening:
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Fax:
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How would you prefer to be contacted
regarding your quote?
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If you would prefer to be contacted by phone,
please let us know the best time to call:
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Ownership:
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Location Address:
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Street:
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City:
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State:
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Zip code:
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Interest
of premises:
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Program:
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Description of operations:
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Mortgagee name & address:
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LIMITS OF INSURANCE
and OPTIONAL COVERAGES
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Building:
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Replacement cost:
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$
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Actual cash value:
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$
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Construction: Frame
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Masonry: Noncombustible:
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Fire resistive:
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Sq. foot area of each building:
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Sq. foot area occupied by applicant:
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Year of construction:
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Number of stories:
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Business personal property:
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Deductible:
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Exterior glass:
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Sign:
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Money & Securities
$10,000 Inside/$2,000 outside:
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Systems breakdown / boiler & machinery:
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Accounts receivable:
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Valuable papers:
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Business computer: Hardware:
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Software:
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Employee dishonesty:
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Business liability:
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Additional insured name & address:
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Non-owned & hired automobile:
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Annual sales:
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Annual payroll:
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3 YEAR PRIOR
CARRIER
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Policy #
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Expiration date:
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Premium:
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Policy #
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Expiration date:
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Premium:
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Policy #
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Expiration date:
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Premium:
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LOSS HISTORY
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Date of loss:
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Loss description:
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Amount:
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Date of loss:
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Loss description:
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Amount:
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Date of loss:
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Loss description:
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Amount:
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REMARKS
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