For Help Call 281-858-8668 |
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Fields marked (*) are mandatory. |
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Agent Name* | |
Agent Number* | |
Agent PH #* | |
Agent Fax # | |
Name of Business* | |
Name of Owner* | |
Type of Entity* | |
Federal Tax I.D. # or Social Security # ? | |
Address* | |
Phone #* | |
Fax # | |
E-Mail* | |
Description/Nature of Business?* | |
How many years in business? | |
OR - How much expeience in this field? | |
Annual Payroll* | |
Annual Gross Receipts/Sales* | |
How many Full Time employees?* | |
How many Part Time employees?* | |
How much contents coverage needed? | |
This form is for indication ONLY |
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To obtain a full quotation, we will require the following: |
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Copy of existing policy declarations page required |
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Claims/Loss History (5 years) with Insurance Company Loss Runs |
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Remarks | |
All items marked * must be answered to recieved a response! |
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What deductibles do you prefer? | |
Type of Contents | |
How much square footage does your business occoupy?* | |
Total building square footage* | |
Is Bldg sprinklered? | |
Alarm? | |
Year Bldg built?* | |
Construction Type?* | |
If other please describe | |
If building owned, how much coverage required? | |
What limits of liability?* | |
Limit if other | |
Any losses?* | |