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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Gross Receipts: |
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Definition
New businesses may estimate their gross receipts,
but we need this information to obtain a quote. |
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Grooming
Service: |
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Commercial General
Liability / Business Owners Policy |
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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 PROFESSIONAL LIABILITY INSURANCE |
Professional Liability
Insurance:
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Number of Independent Contractors Veterinarians:
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Number of Employee Veterinarians:
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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) |
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Building Insurance? |
(optional and may include 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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Prior Claims: |
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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. Copyright 2012 Stratum
Insurance Agency, LLC |