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Business Insurance Quote
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| Name |
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| Business Name |
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| Street Address |
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| Street Address 2 |
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| City, State, Zip |
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| Phone Numbers |
Home Work |
| Email Address |
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| Business Activities |
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| 1.Type of organization |
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| 2. How many owners, partners, or officers? |
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| 3. How many employees, excluding owners, partners or officers? |
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| 4. How many years have you been in business? |
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| 5. Last year's payroll: |
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| 6. This year's projected payroll: |
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| 7. Last year's gross sales: |
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| 8. This year's projected sales: |
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8. Describe your business activities
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9. Have you had losses or claims in the past 5
years? |
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If yes, please give description, date and amount paid for each
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| Coverage Selection |
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| Please indicate the desired coverage you would like quoted. |
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| General Liability/Contractors |
Crime |
| Property |
Workers Comp |
| Equipment |
Boiler & Machinery |
| Builder's Risk |
Garage and Dealers |
| Comments |
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