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General Information
Contact Name *
Email *
Business Name
Address
City
State
Zip
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Business Phone
Fax
Current Insurance Company
(not agency)
Company Name
Policy Expiration Date
Current Insurance Coverages
Current Coverages
Bond
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Business Information
# of Full-Time Employees
# of Part-Time Employees
How long in Business? (yrs)
How many locations?
Please give a brief description of your business and clientele
Property/Premises Information
Address
Occupancy Status
Owner
Tenant
Year Built
% Occupied
Sprinklers
Yes
No
Construction Type
Frame
Brick Veneer
Stucco
Metal
Concrete
Stories
# Basements
Sq. Footage
Burglar Alarm
Yes
No
Building Value
Contents
Other Property (specify)
Insurance Information
Other
Annual Gross Sales: (before taxes)
Number of Employees
Annualized Payroll
Cost of any Subcontracted Work
Limits Requested
$300,000
$500,000
$1,000,000
$2,000,000
Describe any claims you've had in the past 5 years
Additional Comments
* = Required Field
Disclaimer Notice
- The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.
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15621 S. Telegraph Rd
Monroe, MI 48161
phone: (734) 241-1133
Fax: (734) 241-9275
Monday through Friday
8:30am-5:00pm
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