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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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Location: |
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| Type of Notary: |
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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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PROFESSIONAL LIABILITY
(E&O) SECTION - OPTIONAL |
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Professional Liability Limits: |
$
($250,000/$250,000 will be quoted if nothing is entered) |
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| Full Time Employees: |
Part-Time: |
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# of independent contractors that work for you
exclusively: |
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independent contractors |
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Number of Partners/Execs: |
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What
types of clients do you service: |
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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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| Annual Payroll: |
$
(if none, write "none") |
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| Claims: |
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| Other: |
Do your customers sign a
contract or written agreement
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| Do you provide escrow
services (e.g. setting up accounts, transferring funds etc.)? |
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Do you use any independent contractors that are
not working exclusively for you? |
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| Retroactive Coverage
Options: |
If you currently
have errors and omissions insurance in force, please let us know
with which carrier and the retroactive date shown on your
declarations page (you can provide this information later):
Enter Info Here:
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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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Building Security System? |
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PROPERTY INSURANCE -
OPTIONAL |
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Do you currently
have insurance (if yes, with what carrier?
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Current Premium:
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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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Notary Insurance - Mobile Notary
Insurance - Errors and Omissions Insurance - General Liability Insurance for
Notaries |
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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 2012 Stratum
Insurance Agency, LLC |