SMALL BUSINESS INSURANCE

To help us supply you with the most accurate quote possible, please answer as many questions
as you can with the most accurate information available to you.

Information submitted will be held confidential and will be used for quote purposes only. Submission
of application information in no way obligates you to purchase any product or insurance, nor does it represent any agreement to provide coverage under any insurance policy.

BUSINESS INFORMATION
First Name:
Last Name:
Name of Business:
E-mail address:
Daytime Phone Number:  
Evening Phone Number:  
Fax Number:
How would you prefer to be contacted regarding  your quote? Phone   Fax   Mail   E-mail
If you would prefer to be contacted by phone,
 please let us know the best time to call.		 AM   PM
Address:
City:
State:
Zip code:
Years in Business:
Policy Period:
Individual Partnership Corporation Joint Venture Other

LOCATION TO BE INSURED INFORMATION
Address:
City:
State:
Zip code:
Interest of premises:
Owner Owner/Lesser Service
Office Habitational    
Program:
Retail Wholesale Service
Office Habitational    
Description of Operations:
Mortgagee Name & Address:

LIMITS OF INSURANCE and OPTIONAL COVERAGES
Building:
Replacement Cost: $
Actual Cash Value: $
Construction: Frame:
Jointed Masonry:
Masonry: Noncombustable:
Fire Resistive:
Sq. foot are of each building:
Sq. foot area occupied by applicant:
Year of Construction:
Number of Stories:
Business Personal Property:
Deductible:
Exterior Glass
Sign
Money & Securities
($10,000 Inside/$2,000 outside):
Systems Breakdown / Boiler & Machinery
Accounts Receivable:
Valuable Papers:
Business Computer: Hardware:
Software:
Employee Dishonesty:
Business Liability:
Additional Insured Name Address:
Non-owned hired automobile: Yes No
Annual sales:
Annual payroll:

3 YEAR PRIOR CARRIER
Policy # Expiration Date: Premium:
Policy # Expiration Date: Premium:
Policy # Expiration Date: Premium:

LOSS HISTORY
Date of loss: Loss description: Amount:
Date of loss: Loss description: Amount:
Date of loss: Loss description: Amount:

REMARKS


Quotation Forms


About the Agency | The Agency's Principals
About Our Staff | Products and Services | Links | Contact Us | Home


Copyright 2002© The Mines Press