Business Liability Insurance Quote Request
Our Agency has Package Policies, with a broad range of coverage for your type of business.  The flexibility of these packages allows us to customize a policy for your specific needs.  We are able to offer to you an appraisal and survey your Insurance exposures.
Company Information
Owner's Name:
Nature of Business/ Description of Operations:
Legal Entity:	Individual Partnership Corporation
DBA:
Street Address:
City/State:
Zip Code:
Phone:
Fax:
E-mail Address:
Covered Property Information
Property Address:
City/State:
Zip Code:
Did you own or lease the location:	Lease Own
If Own, type of tuilding and date purchased (i.e. Office, Industrial, Apartment):
List number and type of occupants in building:
Construction Type:	Wood Frame Brick / Masonry Masonry Veneer Steel
# of Sq Ft occupied:
Year Built:
# of Units to be insured:
Percentage Building Sprinklered:	None Partially All
Type of Parking available:	None Private Lot Public Lot Garage Street
Is there a Pool? / Fenced? :	No Yes / No Yes
Type of Security System:	None Central Local Guard
Building Imrovements and Date (if any):
Coverage To Quote
Building Amount:
Building Contents Amount:
Loss of Income Amount:
Deductible:	250 500 1000 2500 5000
Liability Amount:	100,000 300,000 500,000 1,000,000 2,000,000
Miscellaneous Coverage and Amounts:
Underwriting Information
Renewal Date:
Current Company:
Give a brief description of any losses in the last 5 years: