Small Business Insurance

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.
 

Business Information
Your Name:    
    (First)                                                             (Last)
Name of Business:  
Address:    
 City:      State:     Zip:
Phone Numbers:   (Day)       (Evening)
Fax:  

How would you prefer to be contacted regarding your quote?
                                         Phone          Fax            Mail             E-mail
                                          If by phone, when is best time:   am   pm
E-Mail address:  
Location Address:  
City:    State:    Zip:
Years in Business:  
Policy Period:  

                                       Individual    Partnership    Corporation    Joint venture   Other
Interest of premises: Owner     Owner/Lessor    Service  Office   Habitational 
Program:  Retail    Wholesale           Service  Office     Habitational

   Description of operations:

Mortgagee name & address:

LIMITS OF INSURANCE and OPTIONAL COVERAGES

Building:  
Replacement Cost: $             Actual Cash Value:  $
Construction:  Frame    Joisted masonry   Masonry/Noncombustible   Fire resistive
Sq Ft area /each Bldg:      Sq Ft area occupied by applicant:
Year of Construction:                 Number of stories:  

Business Personal Property:
Deductible:     
     Exterior glass               Sign

Money & securities $10,000 Inside/$2,000 outside: 

Systems breakdown / boiler & machinery: 

               Accounts Receivable:       Valuable Papers:

  Business Computer Hardware:                   Software:

              Employee dishonesty:        # of Employees:

Business Liabiltiy:  

Additional insured name & address:

Non-owned & hired automobile:  Yes No
Annual sales:        Annual Payroll: 

3 YEAR PRIOR CARRIER 

     Policy #:      Expiration Date:        Premium:  
     Policy #:      Expiration Date:        Premium:  
     Policy #:      Expiration date:        Premium:  

LOSS HISTORY
     Date of loss:      Loss description:          Amount:
     Date of loss:      Loss description:          Amount:
     Date of loss:      Loss description:          Amount:

REMARKS

                                                                                     

©2006 Irving Weber Associates, Inc.