Business Insurance

BUSINESS INSURANCE: Business insurance for manufactures, miscellaneous retail, wholesale, service industry, contractors and companies large or small. This program can also provide premise liability to meet the landlord insurance requirements. Contents, business personal property, loss of rents, loss of use and liability coverage is available. Please complete the Business Insurance Worksheet below. Insurance is available in all 50 states.

We have other insurance program worksheets you can select from the InsuranceCompany.com main menu option or clicking on the InsuranceCompany.com logo to the right. If you have an in-home business please select the home business option. If you are a small contractor please select the artisan contractor option. If you have a small to medium size retail business such as a book store, shoe store, florist shop or a beauty salon type business please select the business owner policy option instead.

* = required information

BUSINESS INSURANCE WORKSHEET
First Name:*
Last Name:*
Business Name:
Address:*
City:*
State:*
Zip Code:*
Phone Number:*
Fax Number:
eMail Address:*

UNDERWRITING INFORMATION
Number of Owners:*
Number of Employees:*	(or Enter NONE)
Payroll of Owners:*
Payroll of Employees:*	(or Enter NONE)
Total Annual Gross Receipts:*
Total Annual Sub Costs:
Business License Number:
License Type:
Years of Experience:*	(or Enter NONE)
How many years have you operated under your current Business Name?
Have you use any other Business Names during the past 5 years?	Yes No
Is This Business Open 24 Hours A Day?	Yes No
Any Deep Frying (Food)?	Yes No
Is There Any Manufacturing, Mixing, Re-Labeling or Repackaging of Products?	Yes No
Is there Filing Of Propane Tanks?	Yes No
Please Describe the Nature of Your Business and ANY Unusual Exposures:*

BUILDING & PROPERTY INFORMATION

Total Square Footage of the Building Your Business Is In:*

Total Square Footage of Your Business Only:* (or Enter SAME)

Square Footage of the Customer Area Only:

How Many Stories:

If Two Stories, Ground Floor Square Footage:

Construction Type:

Roof Type:

Roof Updated? Yes No

If Yes, Year Roof was Updated:

Protection Distance:

Is the Business in a Brush Area? Yes No

Is there Storage more than 1500 Sq Ft? Yes No

Are there Smoke Detectors at this Location? Yes No

Fire Extinguisher? Yes No

Deadbolts on All Doors? Yes No

Circuit Breakers? Yes No

Electrical Updated? Yes No

Heating - Air Conditioning, Thermostatically Controlled?: Yes No

Heating - Air Conditioning, Central? Yes No

Plumbing Updated? Yes No

If Yes, Year Plumbing was Updated:

Interior Automatic Fire Sprinklers:

Theft Alarm:

Fire Alarm:

Any Restaurants in your Building? Yes No

Any Restaurants in your Building "Next to Your Business"? Yes No

CLAIMS INFORMATION

Losses-Claims in the last 5 years:

If yes, Date, Amount Paid and Description of Each Loss-Claim:

COVERAGE INFORMATION
Current Insurance Company:
How much are You Paying Now?:
Liability Limit Requested:*
Building Limit Requested:
Building Deductible Requested:
Business Personal Property (Contents) Limit Requested:
Contents Deductible Requested:
Loss Of Income Limit Requested:
Questions or Comments or Additional Coverage you may need:
Please press the Submit Button ONLY ONE TIME Wait a few moments for an online acknowledgement Thank you for your inquiry

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BUILDING & PROPERTY INFORMATION
Total Square Footage of the Building Your Business Is In:*
Total Square Footage of Your Business Only:*	(or Enter SAME)
Square Footage of the Customer Area Only:
How Many Stories:
If Two Stories, Ground Floor Square Footage:
Construction Type:
Roof Type:
Roof Updated?	Yes No
If Yes, Year Roof was Updated:
Protection Distance:
Is the Business in a Brush Area?	Yes No
Is there Storage more than 1500 Sq Ft?	Yes No
Are there Smoke Detectors at this Location?	Yes No
Fire Extinguisher?	Yes No
Deadbolts on All Doors?	Yes No
Circuit Breakers?	Yes No
Electrical Updated?	Yes No
Heating - Air Conditioning, Thermostatically Controlled?:	Yes No
Heating - Air Conditioning, Central?	Yes No
Plumbing Updated?	Yes No
If Yes, Year Plumbing was Updated:
Interior Automatic Fire Sprinklers:
Theft Alarm:
Fire Alarm:
Any Restaurants in your Building?	Yes No
Any Restaurants in your Building "Next to Your Business"?	Yes No

CLAIMS INFORMATION
Losses-Claims in the last 5 years:
*If yes, Date, Amount Paid and Description of Each* Loss-Claim:**

BUSINESS INSURANCE WORKSHEET

UNDERWRITING INFORMATION

BUILDING & PROPERTY INFORMATION

CLAIMS INFORMATION

COVERAGE INFORMATION

Copyright 1997-2003. Del Amo. All rights reserved.

Copyright 1997-2003. Del Amo. All rights reserved.