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On-Line Wholesale and
Distributors' Insurance
Online Quote Form
One Simple Form - takes only 2-3 Minutes!


Your Personal and Company Data:

Your Name:
Your Company's Name:
Street Address:
City:
State:
Zip/Postal:
E-Mail (REQUIRED):
E-Mail again for accuracy:
Phone:
Fax (optional):
 


Currently Insured?
(If yes, list carrier, and # of years
continuous. If none, type NONE)
 
Type of Business:
Retail    Wholesale
Office    Other
 
List Claims & Amounts Paid
(If none, type NONE)
 
Years In Business:
 
Business type:
(proprietorship, corporation, etc.)
 
Describe Business in detail:
(i.e., Delicatessen and sandwich shop, etc.)
 
 


 
Underwriting Information:
 
Describe IN DETAIL,
Your Business Operations:
 
Ownership & Payroll Data:
List Employee's Annual Payroll Here (if none, enter $0): $ Insert # of
Employees here:
 
Location & Sales Information:
Insert Annual Gross Revenues from this operation here: $ Square Footage of office or business location:
 
Type of Building (wood frame, concrete, etc.): Number of Stories:
 
Are there other business/residences in this building (describe)?: Describe safety features (alarm, sprinklers, fire protection, etc):
 
Coverage Desired: (Check One Please)
The Coverage I Am Looking For:

Liability Only
Liability & Business Contents
Liability, Building & Contents Coverage
A Package Policy Including the Above,
        Plus Miscellaneous Coverages

NOTE: Don't worry if you are not exactly sure about coverage type... we will suggest the best coverage for you - just try to tell us what you are looking for! (If we need more info. we will let you know.)
 
Liability Coverage:
($300,000, $500,000, $1 Million, etc.)
$
 
Business Contents Coverage:
(The amount of your personal business property)
$
 
Building Coverage:
(The amount of building coverage if you own your bldg.)
$
 
Miscellaneous Coverage:
(List any special coverage peculiar to your business, such as Garagekeepers Legal, Loss of Earnings, Valuable Papers, etc.)
$
 
 
Send my quotation via: E-Mail Fax
Regular Mail
Please Call by Phone!

 
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