Business Owners Quote Request

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Business Owners Insurance Request Form

Name

Your Company's Name

Address

Phone

Fax

Currently Insured?

Type of Business:

Retail

Wholesale

Office

Other

List Claims & Amounts Paid

Years in Business

Describe Business in detail

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

Locations & 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)

Liability Only

Liability & Business Contents

Liability, Building & Contents Coverage

A Package Policy Including the Above

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

Send my quotation via

E-Mail

Fax

Regular Mail

Call me by Phone!

Java Agency
4515 Main Street P.O. Box 133 Java Village, NY 14083
Phone #: (585) 457-3881 Fax #: (585) 457-3897
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