Independent Insurance Agent Advantage
Contact Us
Home
Personal Life / Health
Commercial Auto
Group Health
Workers Comp
Business
Business Package Insurance Quote
Business Package Insurance Quote
(
Texas residents only.)
GENERAL INFORMATION
NAME OF BUSINESS
CONTACT NAME
ADDRESS
CITY
STATE
ZIP
BUSINESS PHONE
FAX PHONE
BEST TIME TO CALL
AM
PM
E-MAIL ADDRESS
LOCATION ADDRESS
Type "same" if same as above. List additional locations in the "additional information" box at the end of the form.
CITY
STATE
ZIP
PLEASE DESCRIBE YOUR BUSINESS, PRODUCT AND/OR SERVICE
PLEASE TELL US ABOUT YOUR BUSINESS
# FULL-TIME
EMPLOYEES
# PART-TIME
EMPLOYEES
NUMBER OF
YEARS IN BUSINESS
PROJECTED GROSS
ANNUAL RECEIPTS
PROJECTED TOTAL
ANNUAL PAYROLL
PLEASE PROVIDE INFORMATION ON YOUR INSURANCE CARRIER
INSURANCE CARRIER
POLICY NUMBER
GL PREMIUM
PROPERTY
PREMIUM
YOUR POLICY
RENEWAL DATE
HOW MANY YEARS WITH
CURENT INSURANCE CARRIER?
(MM/DD/YY)
If prior policy has been with a different carrier than the current, please list in the additional comments section at the end of the form.
PLEASE LIST ANY LOSSES OR CLAIMS YOU HAVE HAD IN THE PAST THREE YEARS. IF NONE, PLEASE TYPE NONE IN THE FIELD.
ABOUT THE PROPERTY
BUILDING AGE/YEAR BUILT
TYPE OF BUILDING
STORIES:
OTHER OCCUPANCIES
SQ. FT. OCCUPIED
Choose
Frame
Stucco
Masonry/Brick
Fire Resistive
Other
.
If the building is over 25 years old, please answer the following:
YEAR ELECTRICITY UPDATED
ARE THERE CIRCUIT BREAKERS?
Yes
No
YEAR PLUMBING UPDATED
COPPER OR GALVANIZED?
Copper
Galvanized
OTHER
LAST YEAR BUILDING WAS ROOFED
TYPE OF ROOFING MATERIAL
TYPE OF HEATING SYSTEM
PROTECTIVE DEVICES
BURGLAR ALARM?
CENTRAL STATION OR
LOCAL ALARM?
ALARM COMPANY NAME
SPRINKLERS?
SMOKE DETECTORS?
Y
N
Central
Local
Y
N
Y
N
PROPERTY COVERAGE LIMITS
BUILDING
CONTENTS (EQUIPMENT,
INVENTORY, SUPPLIES, ETC.)
DEDUCTIBLE
Choose
$250
$500
$1,000
LOSS OF INCOME
MONEY & SECURITIES
GLASS OR SIGNS
IF YOU HAVE SPECIFIED GLASS COVERAGE, PLEASE PROVIDE DIMENSIONS
GENERAL LIABILITY COVERAGE LIMITS
GENERAL LIABILITY AMOUNT
NON-OWNED/HIRED AUTOMOBILE LIABILITY
Choose
$300,000
$500,000
$1,000,000
Y
N
CLASS CODE*
PAYROLL/SALES EXPOSURE
*Can be found on current policy
DO YOU SUBCONTRACT
ANY WORK OUT?
IF YOU DO SUBCONTRACT,
WHAT PERCENTAGE?
YES
NO
DO YOU REQUIRE ANY SPECIAL ENDORSEMENTS? IF SO, PLEASE LIST BELOW
(example: blanked additional insured or waiver of subrogation)
ADDITIONAL INFORMATION
Please list the addresses of all locations, along with any pertinent additional information you may have.
Back To Top Of Form
Privacy Statement
Disclaimer
Website Design
and
Website Development
Edge
Dallas, Texas
Verhagen, Glendenning & Walker, LLP, dba Glendenning Insurance | Verhagen, Glendenning & Walker, LLP, dba VGW, LLP | Copyright© 2009 | Dallas, Texas
