Business Owner's Package Quote

General Information

Name of Insured:
City:    State:    Zip:
Business Phone:    Fax Number:
Email Address:
Location Address
(type "same" if same as above):
City:    State:    Zip:

Property Questions

Age of building
/Year Built:
Type of building
Number of
Square feet
you occupy:
sq. ft.
If the building is over 25 years old, please answer the following:
Year Electricity was updated:

Is it on circuit breakers?:

Yes   No

Year Plumbing was updated:

Copper or Galvanized plumbing?:

Copper   Galvanized   Other:

Year Building was last re-roofed:

Type of roofing material:

Type of heating system in the building:

Protective Devices

Burglar Alarm:
Central Station
or local alarm?:
Name of
alarm company:
Is the building
Are there
smoke detectors?:
Y   N
 Central Station
 Local Alarm
Y   N
Y   N

Liability Questions

Please provide information on previous insurance carrier:
Previous Ins. Carrier:
Policy number:
Prior premium:
Policy renewal date:
Please provide information about your business:
Years in business:
Projected Gross annual receipts:
Projected annual payroll:
    Describe your business, product or service:

Coverage Limits

Contents (equipment,
inventory, supplies, etc.):
Loss of Income:
Money and Securities:
Glass or signs:
General Liability Limit:
Non-owned and Hired
Automobile Liability:
Is liquor liability needed?
Yes   No
    If Glass Coverage is needed, please provide dimensions:
    Please list other coverages you may need:

Miscellaneous Information

Name of Additional Insured
(Landlord or vendor):
Mailing Address:
City:    State:    Zip:

Additional Comments

Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough fields above, please enter them here.

Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.


I understand that my coverage (or changes in coverage) ARE NOT binding via this on-line request; Changes ARE considered binding when I receive an email (or fax) response from my agent indicating that they have received my request.

 I have read and agree with the disclaimer.

(Box must be checked before request can be sent)