Business and Office Owners Insurance Request

For your protection and security, the information you provide is sent to us via a secured server. Please fill out this form as completely as possible to ensure an accurate request.

Personal Information

Select Your State

Please Note: We only write insurance for these states.

Address

What is your address?

Street Address Address Line 2 City State ZIP Code

Name*

What is your name?

First Last

Telephone Number (Business)*

What is your business telepone number?

Telephone Number (Home)

What is your home telepone number?

Email Address*

What is your email address?

Fax

What is your fax number?

Underwriting Information

Nature of Business

What is the nature of your business?

Is the business a corporation, partnership or sole proprietorship?

Corporation
Partnership
Sole Proprietorship

Number of Owners

How many owners?

Please enter a number greater than or equal to 0.

Number of Employees

How many Employees

Please enter a number greater than or equal to 0.

Payroll of owners

What is the payroll amount of the owners?

Payroll of employees

What is the payroll amount of the employees?

Total Annual Gross Receipts

What is the total annual gross?

Business License Number

What is the business license number?

License Type

What is the license type?

Years of Experience

Years of experience in this business?

Please enter a number greater than or equal to 0.

Years Operated Under Current Name

How many years have you operated under your current business name?

Please enter a number greater than or equal to 0.

Other Business Names

Have you used any other business names during the past 5 years?

Yes
No

Open 24 hours

Is this business open 24 hours a day?

Yes
No

Deep Frying

Any deep frying (food)?

Yes
No

Manufacturing

Is there any manufacturing, mixing, re-labeling or repackaging of products?

Yes
No

Propane Tank Filling

Is there filling of propane tanks?

Yes
No

Unusual Exposures

Please describe the nature of your business and ANY unusual exposures.

Building & Property Information

Total Square Footage of Business Building

What is the total square footage of the building your business is in?

Please enter a number greater than or equal to 0.

Total Square Footage of Business Only

What is the total square footage of your business only?

Please enter a number greater than or equal to 0.

Square Footage of Customer Area

What is the square footage of the customer area only?

Please enter a number greater than or equal to 0.

Stories

How many stories is it?

Please enter a number from 0 to 99.

Ground Floor Square Footage

If two stories, what is the ground floor square footage?

Please enter a number greater than or equal to 0.

What type of roof covering?

Was the roof updated?

Yes
No

If yes, what year?

Year Roof Updated

Please enter a number from 1700 to 3000.

What is the distance of fire protection?

Brush

Is the building in a brush area?

Yes
No

Storage Area

Do you have a storage area more than 1500 Sq. Ft.?

Yes
No

Smoke Detectors

Are there smoke detectors at this location?

Yes
No

Fire Extinguishers

Are there fire extinguishers?

Yes
No

Deadbolts

Are there deadbolts on all doors?

Yes
No

Circuit Breakers

Are there circuit breakers?

Yes
No

Is the electrical updated?

Electrical Update

Thermostatically Controlled

Is the heading/ air conditioning thermostatically controlled?

Yes
No

Central

Is the heating/ air conditioning central?

Yes
No

Plumbing Updated

Has the plumbing been updated?

Yes
No

If yes, what year was the plumbing updated?

Year Plumbing Updated

Please enter a number from 1700 to 3000.

Automatic Fire Sprinklers

Does the building have interior automatic fire sprinklers?

Yes
No

Theft Alarm

Is there a theft alarm?

Yes
No

Fire Alarm

Is there a fire alarm?

Yes
No

Restaurants

Are there any restaurants in your building?

Yes
No

Restaurants Next to Business

Are there any restaurants in the building next to your business?

Yes
No

Claims Information

Were there any losses or claims in the last 5 years?

Losses – Claims

Yes
No

What is the date, amount paid and description of each loss or claim?

Coverage Information

What is the current insurance company?

Amount Current Coverage

How much are you paying now?

Liability Limit

What is the liability limit requested?

Building Limit

What is the building limit requested?

Building Deductible

What is the building deductible requested?

Business Personal Property

What is the business personal property (contents) limit requested?

Contents Deductible

What is the contents deductible requested?

Loss of Income Coverage

What is the loss of income requested?

Questions, Comments or Additional Coverage

Are there any questions, comments or additional coverage required?

Captcha

Print Form

Business and Office Owners Insurance Request

Office And Business Owner Insurance Quote Request

Personal Information

Underwriting Information

Building & Property Information

Claims Information

Coverage Information