BUSINESS INSURANCE

QUOTE FORM

Name of Owner: ______________________________________________

Home Address:________________________________________________

Name of Business:______________________________________________

Business Address:______________________________________________

How many years in Business_____Corporation / Partnership / Individual

Owners S/S #_____________Fed Tax#____________State Tax#________

Owners Date of Birth___________Type of Business_________________

How many employees_______Estamted Annual Payroll______________

Estimated Gross Sales____________Contractors Lic#________________

Age of Building_____Sprinklers Yes /No Alarm Yes /No Central Yes /No

Previous Insurance Company_________________# of Claims_________

Hm Phone #____________Wk Phone #____________Fax #___________

*Additional Information for Workers Compensation 3 years of loss runs:

Owners / Officers

Include Name / Date of Birth / Title / % of Ownership / Salary