Commercial Quote Survey

 

BUSINESS INFORMATION:

 Contact Name:  

Title:  

Mailing Address:

Street Address:  

 

Address (cont.):  

City:  

State/Province:  

Zip/Postal Code:  

Business Name:  

    

Location Address:    

City/State:                

Zip Code:                

County:                  

Work Phone:           

FAX:                       

Email:                     

Nature of Business:     

Other Occupancies:    

Federal Tax ID#:                   

NJERN#:                    

Business Type:

                      Entity
                      Corporation
                      Partnership
                      Individual
                      Other

PROPERTY COVERAGE:

Building Construction:

Alarm:  Sprinkler:

  Date of Construction:          -- mm/dd/yy

  Premises Square Footage:   

  BUILDING LIMIT:                 

CONTENTS LIMIT:                   

BUSINESS LIABILITY COVERAGE:

  Annual Sales Receipts:           

  Annual Payroll:                     

  Number of Employees:        

  LIMIT OF LIABILITY:             

BUSINESS AUTOMOBILE:

LIMIT OF LIABILITY:               

Vehicle List*:    

                    Year\Make\Model           Comprehensive     Collision

  1.           

  2.           

  3.           

  4.           

  5.           

  6.            

  7.           

  8.           

  9.           

  10.           

*If your company has more then ten (10) vehicles then please call to make an appointment.

WORKERS COMPENSATION

        yes
        no

AP Chango Webmaster.
Copyright © 2002 America's Insurance Center. All rights reserved.
Revised: January 09, 2003