| Tell us about yourself |
| First Name: |
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| Last Name: |
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| Contact Phone: |
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| Fax: |
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| E-Mail: |
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| Address: |
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| City: |
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| State: |
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| Zip: |
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| Tell us about your business |
| Name of your Business: |
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| Describe your Business: |
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| Is this a new business? |
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| If NO what year was your business started? |
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| No of Employees: |
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| Annual Sales |
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| Annual payroll- employees only |
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| Building Construction |
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| Burglar Alarm |
Yes |
No |
| Fire Alarm |
Yes
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No |
| Sprinkler System |
Yes |
No |
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| Tell us about current coverage |
| Type of Coverage: |
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| Policy renew date |
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| Tell us about your choice of coverage |
Covers actual business property necessary to conduct business(ie: computer equipment)
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| Business Property Coverage |
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| Coverage Amount |
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| Select Deductible |
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| Business Liability Coverage |
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| Choose Coverage |
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| Select Deductible |
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| Tell us about your choice of additional coverage |
| In-Home Business Coverage Options |
Yes |
No |
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| General Business property
coverage does not cover all property within the business structure. Check off any of the
following that you may need as well and fill in the coverage you think you may need. |
| Computer Equipment |
Est. Coverage |
| Software |
Est. Coverage |
| Money/Securities |
Est. Coverage |
| Signs |
Est. Coverage |
| Glass |
Est. Coverage |
| Valuable Papers |
Est. Coverage |
| Accounts Receivable |
Est. Coverage |
| Employee Dishonesty |
Est. Coverage |
| Enter your comments or questions in the box below: |
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| The quote you receive is an estimate and although fairly accurate, does not represent exact cost. Because of the many attributes that determine price, an exact figure cannot be given until we discuss further information with you. Thank you for requesting a quote |
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