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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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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Location: |
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PROFESSIONAL LIABILITY
(E&O) SECTION - OPTIONAL |
Professional Liability Limits: |
$
($250,000 will be quoted if nothing is entered) |
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Agents and Brokers: |
Full
Time:
Part Time:
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Property Managers: |
Full Time:
Part Time:
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Full Time:
Part Time:
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Number of Partners/Execs: |
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GROSS RECEIPTS |
(complete the boxes that relate to your business -
if new business, estimate) |
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Sales: |
Residential:
Commercial:
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Property Management or
Leasing: |
Residential:
Commercial:
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Appraisals/BPOs: |
Residential:
Commercial:
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Vacant Land Sales: |
Residential:
Commercial:
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Foreclosures: |
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Raw Land: |
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Total Gross
Sales: |
$ |
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Claims: |
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Do you belong to
any professional associations? |
(if known) |
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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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Location: |
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PROPERTY INSURANCE
(added to the general liability quote) -
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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