INSURANCE   


BUSINESS OWNERS INSURANCE (BOP) QUOTE APPLICATION
Fields marked (*) are mandatory.
General Information
Name of Business*
Address*
City*
State*
Business Phone*
Fax Number*
Email Address*
Contact Name
Location Address (type 'same' if same as above)*
City
State
Zip

Propertry Questions
Age of building/Year Built*
Type of building construction*
Number of stories*
Other occupancies*
Square feet you occupy (sq. ft.)*
If the building is over 25 years old, please answer the follwing
Year Electricity was updated *
Is it on circuit breakers? *
Year Plumbing was updated *
Copper or Galvanized plumbing? *
If Other
Year Building was last re-roofed *
Type of roofing material *
Type of heating system in the building *

Protective Devices
Burglar Alarm*
Central Station or local alarm?*
Name of alarm company
Is the building sprinklered*
Are there smoke detectors*
Liability Questions
Please provide information on previous insurance carrier
Previous Ins. Carrier*
Policy number*
Prior premium*
Policy renewal date*
 
Please provide information about your business
Years in business*
Projected Gross annual receipts*
Projected annual payroll*
Business Type
Describe your business, product or service*
Number of attorneys or the number of brokers or licensed sales associates?

Coverage Limits
Building
Contents (equipment, inventory, supplies, etc.)
Deductible
Loss of Income
Money and Securities
Glass or signs
General Liability Limit
Non-owned and Hired Automobile Liability
Is liquor liability needed?
If Glass Coverage is needed, please provide dimensions
Please list other coverages you may need

Miscellaneous Information
Name of Additional Insured (Landlord or vendor)
Mailing Address
City
Zip
State

Additional Comments
Additional Comments
 

 


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