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Professional
Liability and/or General Liability Insurance Quote Request |
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ABOUT THE OWNER / PRINCIPAL |
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Company Name:
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First Name:
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Last Name: |
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Address: |
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City: |
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State: |
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Phone: |
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| Zip Code: |
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E-mail: |
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Confirm E-mail: |
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ABOUT THE BUSINESS |
| Name
of Business: |
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| Type of Business: |
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| Description of Business: |
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Year Started: |
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Years experience in industry: |
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| Tax ID # |
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| Do you belong to
any professional associations? |
(if known) |
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Gross Receipts: |
Prior Year $
(if new business, write NEW and estimate an amount) |
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Current
Year $
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Estimates for Next
Year $
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COMMERCIAL GENERAL LIABILITY SECTION - OPTIONAL |
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General Liability Limits: |
$
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Space Occupied (sq feet): |
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Year Building Built: |
(estimate is
acceptable) |
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Building Security System? |
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COMMERCIAL INSURANCE -
OPTIONAL |
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| How many ATVs or Snowmobiles
do you have? |
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Do you currently have
commercial auto insurance (if yes, with which carrier)?
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Current Premium:
(this helps us compare rates)
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Do you have any other information
about your business, or comments that you would like to
share? Please place special requests here, such as extra coverage
for special items. |
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NO COVERAGE IS BOUND,
OFFERED, ISSUED THROUGH THIS ELECTRONIC COMMUNICATION, ALL POLICIES MUST BE
UNDERWRITTEN AND APPROVED BY THE CARRIER. DO NOT CANCEL YOUR CURRENT
INSURANCE. |
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Copyright 2011 Stratum
Insurance Agency, LLC |
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General Liability Insurance | Business Owners
Policies | Professional Liability Insurance |
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