Professional
Liability and/or General Liability Insurance Quote Request |
ABOUT THE OWNER / PRINCIPAL |
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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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 do any
genetic testing, live animal testing, or testing of volatile
substances (such as radioactive)? |
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Which of these
are part of your operation? |
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COMMERCIAL GENERAL LIABILITY SECTION - OPTIONAL |
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Full Time Employees: |
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Part-Time: |
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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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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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Business personal property
and equipment? |
(office equipment, supplies, furniture) (we can quote
coverage for inventory and food spoilage based on your industry) |
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Year Building Built: |
(estimate is
acceptable) |
Building Insurance? |
(tenant improvement coverage, or for the building) |
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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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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.
Biotech Insurance, Life Sciences Insurance,
R&D Insurance, Medical Device Insurac
Copyright 2011 Stratum
Insurance Agency, LLC
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