List Employee's Annual Payroll Here (if none, enter $0):
$
Insert # of Employees here:
Location & Sales Information:
Insert Annual Gross Revenues from this operation here:
$
Square Footage of office or business location:
Type of Building (wood frame, concrete, etc.):
Number of Stories:
Are there other business/residences in this building (describe)?:
Describe safety features (alarm, sprinklers, fire protection, etc):
Provide breakdown percentages of work provided:
Passenger %
Truck %
Off-the-Road %
Coverage Desired: (Check One Please)
Policy Type I am Interested In:
Claims Made Form
Occurrence Form
Limits of Liability Coverage I am Interested In:
$250,000
$500,000
$1 Million
$5 Million
Limit of business property needed:
$
Limit of Garagekeepers Coverage Needed: (Total amount of vehicle left in your possession.)
$
NOTE: Don't worry if you are not exactly sure about
coverage type... we will suggest the best coverage for you - just try to tell us what you are looking for! (If we need more info. we will let you know.)
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