| BUSINESS OWNER QUOTE |
| First Name : |
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| Last Name : |
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| Business Name : |
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| Address : |
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| City : |
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| State : |
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| Zip Code : |
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| Phone Number : |
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| Fax Number : |
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| E-Mail Address : |
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| UNDERWRITING QUESTIONS |
| Property County : |
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| Please Describe the Nature of Your Business : |
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| Number of Owners : |
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| Number of Employees : |
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| Payroll of Employees : |
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| Total Annual Gross Receipts : |
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Total Square Footage of the Building Your
Business
Is In : |
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| Square Footage Of Your Business Only : |
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| Current Insurance Company : |
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| Years of Experience : |
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| How Many Years Have You Operated This Business : |
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| How Many Stories : |
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| Construction Type : |
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| Is This Business Open 24 Hours A Day? : |
Yes
No
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| Any Deep Frying (Food)? : |
Yes
No
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If An Office Risk, Is E&O With 1 Million Admitted
Coverage Carried? : |
Yes
No
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| Fire Extinguisher : |
Yes
No
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| Deadbolts On All Doors? : |
Yes
No
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| Interior Automatic Fire Sprinklers : |
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| Theft Alarm : |
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| Fire Alarm : |
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| Losses-Claims in the last 5 years : |
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If yes, date, amount paid and description
of each loss-claim : |
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| COVERAGE INFORMATION |
| Building Coverage : |
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| Other Structures Coverage : |
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| Business Contents Coverage : |
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| Loss of Income Coverage : |
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| Liability Limits Requested : |
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| Policy Deductible : |
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| Questions or Comments to help the Agent : |
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