Business Owners Insurance Quote Form

Personal and Company Information:
Your Name:
Your Company's Name:
Street Address:
City:
State:	Illinois
Zip/Postal:
E-Mail (REQUIRED):
Phone:
Fax (optional):


Currently Insured? (If yes, list carrier, and # of years continuous. If none, type NONE)

Type of Business:	Retail Wholesale Office Other

List Claims & Amounts Paid (If none, type NONE)

Years In Business:

Business type: (proprietorship, corporation, etc.)

Describe Business in detail: (i.e., Delicatessen and sandwich shop, etc.)


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:

Location & 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)
The Coverage I Am Looking For: Liability Only Liability & Business Contents Liability, Building & Contents Coverage A Package Policy Including the Above, Plus Miscellaneous Coverages
NOTE: Don't worry if you are not exactly sure about coverage type... we will suggest the best coverage for you - just try to tell us what you are looking for! (If we need more info. we will let you know.)

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: (List any special coverage peculiar to your business, such as Garagekeepers Legal, Loss of Earnings, Valuable Papers, etc.)		$

Other Coverages You Would Like Information On:		Commercial Vehicle Bonds, License/Performance Workers Compensation Builders Risk Insurance Commercial Umbrella


Send my quotation via:	E-Mail Fax Regular Mail Please Call by Phone!