BOP Quote

May 20, 2012

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Business Owners Package Quote

Insured Information

Name of Business

Contact Name

Street Address

City

State

Zip

County

Phone Number

Fax

Current Insurance

Company Name (not agency)

Policy Exp. Date:

Current Coverages

Bond		Commercial Auto
Commercial Liability		Commercial Property
Commercial Umbrella		Directors & Officers Liability
Professional Liability		Disability
Group Life		Group Health
Workers' Compensation	Other

About Your Business

Limits Requested

# of Full-time employees

# of Part-time employees

Years in business

How many locations

Annual Sales (in dollars)

Annual Payroll

Please give a brief description
of your business and clientele

Property / Premise Information 1

Street Address

% Occupied

Owner

Sprinklers

Burglar Alarm

Construction Type

Frame		Brick Veneer		Stucco
Metal		Concrete		Other

# Stories

#Basements

Sq. Footage

Building Value

Contents Value

Other Property

Property / Premise Information 2

Street Address

% Occupied

Owner

Sprinklers

Burglar Alarm

Construction Type

Frame		Brick Veneer		Stucco
Metal		Concrete		Other

# Stories

#Basements

Sq. Footage

Building Value

Contents Value

Other Property

Property / Premise Information 3

Street Address

% Occupied

Owner

Sprinklers

Burglar Alarm

Construction Type

Frame		Brick Veneer		Stucco
Metal		Concrete		Other

# Stories

#Basements

Sq. Footage

Building Value

Contents Value

Other Property

Past Claims

Describe any claims you've had in the past 5 years

Comments

The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.