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    Business Quote   

Owner's Name

Business Name

Business Address

City

State

Work Number

Fax

Zip

Pager

E-Mail

Business Ownership

Sole Proprietor

Incorporated

Partnership

# of Partners

Brief description of type of work you do

Number Of Employees

Annual Emp. Payroll $

Annual Gross Receipts

Amount paid annually to sub-contractors

Labor

Materials

Liability Limit

 $300,000

$500,000

$1,000,000

$2,000,000

Current Insurance Co.

Expires

Annual Premium

Any Claims during the last 3 years?

Yes

No

If yes, please describe loss and show loss amt. here.

 

Click on Business type below for additional questions:

Retail Shop/Stores  |  Computer/Software Consultants  |  Contractors



Computer/Software Consultants

Do you provide Internet Services:

Do you provide web hosting Services:

Give a description of services provided:

Do you Design Software:

If yes, will this software be sold to the general public:

Please describe how the software will be used:

 

Contractors:

Contractor's Lic. #

Type

Years Experience

Years in Business

Do you work on New Residential Tracts?

Yes

No

If yes, list max. # of units

Do you work on New Condo or Apartment Complexes?

Yes

No

Commercial Bldg. Only

Residential Bldg. Only

Both

% Com

%Res

Quote A.S.A.P.!!!

Quote Prior to my policy expiring.

Just Checking

 

Retail Shops/Stores

Please Indicate what type of shop or store you have:


You will be faxed or Emailed supplemental questionnaires related to your type retail business.

 

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