FAST AND EASY BUSINESS OWNERS INSURANCE PROPOSAL FOR BUSY PEOPLE

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FIRST NAMEFirst Name

LAST NAME

BUSINESS NAMEyour full name

Today's Dateof appointment

Mailing Addressyour full name

Unit #your full name

Cityyour city

STATE

CA

ZIPZIP

CELL PHONECELL PHONE#

BUS PHONE

Emaila valid email

Email again for Accuracya valid email

CURRENTLY INSURED? If yes, list carrier and # of years continuous. If no current insurance, type "NONE"

UNDERWRITING INFORMATION

Type of Business

Type of Business?DentistsRestaurantsMedical OfficesRetail StoresBusiness OfficesWholesale DistributorsMobileArtisan ContractorsGeneral ContractorsChiropractorsVeterinarians

Bus Structurepick one!

Business Stucture?Sole ProprietorPartnershipLimited Liability CorporationCorporation

# Locationspick one!

Number Locations?012345-1010-2020+

List the full address of each location here. One per linemore details

0 / 300

Number of Employees?

Number Employees?0-22-45-1010-2020+

Estimated Annual Payroll?your full name

Annual Gross Revenues?Gross Revs

Square Footage?your full name

TYPE OF COVERAGE

Coverage Desired?Commercial General liability onlyLiability & Business ContentsLiability, Business Contents, & Building

Liability Limits?

Liability Limits Desired?1,000,0002,000,0003,000,0005,000,00010,000,000

Business Equipment Limit?your full name

Business Inventory Limits?your full name

Building Limits if location(s) owned?your full name

Please describe exactly what your business does. Describe in full all products, services, and delivery methods your company offers.more details

0 / 500

List the #employees, payroll, gross revenue, square foot, equipment, inventory, and building limits for each additional location if multiple locations owned.more details

0 / 500

List any special coverages peculiar to your business, such as Garage Keepers, Loss of earnings, etc.more details about your business

0 / 300

Any Claims?Please describe in box to the right

YESNO

If there has been any claims, please list the claim date, amount paid, and a brief description of what happened. If you have had no claims, type "NONE".more details

0 / 250

GET ME MY BUSINESS OWNERS INSURANCE PROPOSAL

Thank you for filling out this form COMPLETELY!

We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By clicking the button below you agree to allow our agency to release this information, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy. We take your privacy and data security very seriously!

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.......................................... Please Upload current Declarations Page or Policy if available ....................................................

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