Business Owners' Protection Application for Quote

(* required information)

General Information
Name of Business
Contact Name *			Title
Email Address*
Mailing Address 1			Location Address 1
Mailing Address 2			Location Address 2
City			Business City
State		AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY	State		AL AK AZ AR CA CO CT DE FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY
Zip Code			Business Zip Code
Quoting Information
Years in Business			Hours of Operation
Year Building Built			Year of plumbing & electrical updates
Total Area of Building			# of stories
Area of Vacant Space in Building
Construciton of Building		Select One Frame Joisted Masonry Masonry/Non-Combustible Fire Resistive
Alarm System		Select One Direct to Police & Fire Central Station No Alarm
Any Products sold direct to public?			yes no
Any other business operations?			yes no
Is there a Commercial Auto Policy in force?			yes no
Are you within 15 miles from any coastal waters?			yes no
Sprinkler System in building?			yes no
Is building owned?			yes no
If Yes, Replacement cost of building			$
Replacement cost of Business Personal Property (contents)			$
Area occupied
Name of Current Insurance Company			Annual Premium
Number of Paid Claims in past 3 years		Select One 0 1 2 3 4+	Total Paid		$
Umbrella Liability
Include Umbrella Liability?		yes no
Limit of Liability		Select One $1,000,000 $2,000,000 $3,000,000 $4,000,000 $5,000,000