Property Quote Form
Please
fill out as much information as possible. Please contact
us with any questions about this form.
|
| BUSINESS
INFORMATION |
| Business
Name: |
|
| Contact
Person: |
|
| Street
Address: |
|
| City,
State, Zip Code: |
|
| Tax
ID Number: |
|
| Preferred
method of contact: |
|
|
E-mail: |
|
|
Telephone: |
|
|
Fax: |
|
| |
|
| CURRENT
INSURANCE INFORMATION |
| Current
insurance company (not agency): |
|
| Policy
expiration date: |
|
| Premium
amount: |
|
| City,
State, Zip Code: |
|
| |
| ABOUT
YOUR BUSINESS |
| Number
of full time employees: |
|
| Number
of part-time employees: |
|
| How
long have you been in business?: |
|
| Number
of locations: |
|
| Annual
Sales: |
|
| |
|
| PROPERTY
INFORMATION - LOCATION #1 |
| Street
Address (if different
than above): |
|
| City,
State, Zip Code: |
|
| Year
Built: |
|
| Square
Footage: |
|
| Type
of Construction: |
|
| #
of Stories: |
|
| Roof
Type: |
|
| Year
the roof was installed: |
|
| #
of Stories: |
|
| Alarm
Type: |
|
|
Owner
Tenant |
| Have
there been any claims in the last
three years?
Yes
No |
| If
yes, please
list all claims in the last three years, including dates and
amount paid: |
|
| Current
Coverage of Building: |
|
| Contents: |
|
| Computer
Equipment: |
|
| Loss
of Use: |
(at least 20% of the Dwelling) |
| Liability: |
|
| Medical
Payments: |
|
| Deductible: |
|
| Do
you have any special endorsements on your policy?
Yes
No |
| If
yes, please describe: |
|
| PROPERTY
INFORMATION - LOCATION #2 |
| Street
Address (if different
than above): |
|
| City,
State, Zip Code: |
|
| Year
Built: |
|
| Square
Footage: |
|
| Type
of Construction: |
|
| #
of Stories: |
|
| Roof
Type: |
|
| Year
the roof was installed: |
|
| #
of Stories: |
|
| Alarm
Type: |
|
|
Owner
Tenant |
| Have
there been any claims in the last
three years?
Yes
No |
| If
yes, please
list all claims in the last three years, including dates and
amount paid: |
|
| Current
Coverage of Building: |
|
| Contents: |
|
| Computer
Equipment: |
|
| Loss
of Use: |
(at least 20% of the Dwelling) |
| Liability: |
|
| Medical
Payments: |
|
| Deductible: |
|
| Do
you have any special endorsements on your policy?
Yes
No |
| If
yes, please describe: |
|
| PROPERTY
INFORMATION - LOCATION #3 |
| Street
Address (if different
than above): |
|
| City,
State, Zip Code: |
|
| Year
Built: |
|
| Square
Footage: |
|
| Type
of Construction: |
|
| #
of Stories: |
|
| Roof
Type: |
|
| Year
the roof was installed: |
|
| #
of Stories: |
|
| Alarm
Type: |
|
|
Owner
Tenant |
| Have
there been any claims in the last
three years?
Yes
No |
| If
yes, please
list all claims in the last three years, including dates and
amount paid: |
|
| Current
Coverage of Building: |
|
| Contents: |
|
| Computer
Equipment: |
|
| Loss
of Use: |
(at least 20% of the Dwelling) |
| Liability: |
|
| Medical
Payments: |
|
| Deductible: |
|
| Do
you have any special endorsements on your policy?
Yes
No |
| If
yes, please describe: |
|
| |
|
|
|
|
| |
Submitting an insurance quotation request
to Alexander & Strunk Insurance does not constitute a binding confirmation
of new or altered insurance coverage. Verbal and/or written confirmation
must be obtained from Alexander & Strunk Insurance to confirm binding or altering
coverage. |
