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Contact
Name: * |
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Company: * |
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Company
Address: * |
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Co. City/State/Zip: * |
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Phone: * |
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Fax: |
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Email: * |
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Years
Company has been in Business: * |
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Type of Business & Description: * |
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Current
Insurance Company (not agency): |
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Policy
Number: |
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Policy
Expiration Date: |
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Current
Annual Premium: |
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General
Liability |
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Limits: |
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Number
of Owners: * |
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Number
of Employees: * |
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Employees Payroll (12 mos period): |
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Types
of Subcontractors used: |
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Subcontractors Payroll: |
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Gross
Sales: |
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Office
Square Footage: |
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Additional Insured: |
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Commercial Auto |
Please attach a
sheet with the following information for each driver and each
vehicle that needs to be insured:
Driver: Full Name, Drivers License, Date of Birth,
Gender, Social Security Number, List of violations/accidents
within last 3 years
Vehicle: Year, Make, Model, Gross vehicle weight, VIN#,
Cost of Vehicle (new), Actual Cash Value, Does it pull a trailer
(if so, include length)
For each vehicle also include desired limits of liability,
personal injury protection, uninsured motorist, and deductible |
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Property |
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Address
(if different then listed above): |
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Replacement Cost: |
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Year
Built: * |
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Type of
Construction: |
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Type of
Wiring: |
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Type of
Roof: |
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Last
Replaced: |
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Square
Footage: |
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Number
of Stories: * |
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following only if the Office/Building is older than 20 years: |
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Wiring
Last Updated: |
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Plumbing Last Updated: |
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Heat/AC
Last Updated: |
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Please list any other information
you feel is important and/or relevant to quoting your commercial
insurance or additional insurance: |
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