E-mail: *
First
Name: *
LastName: *
How
did your hear about us?
Select One
Exsisting client
Flyer
Referral
Smartpages.com ( SBC )
Superpages ( Verizon )
Company
name
Address:
City
& state:
Zip
code:
Home
phone:
Work
phone:
Cell
phone:
Best
time to phone you:
Select One
A.M.
P.M.
What
is the business entity type
Select One
Individual
Nonprofit
Corporation
Year
business started
How
many years experience in industry
Nature
of business (business description)
Provide
property address to be covered?
Do
you own or lease
Select One
Own
Lease
If
owned, what is the value of the property?
If
owed, what is the total square footage of the building?
#1
Name
What
type of property is your building?
Select One
Office
Retail
Industrial
Other
Approximate year built?
Construction
type
Select One
Frame
Concrete tilt up
Steel
Other
#
of stories
Total
square footage of space you lease
Which
of the following features does your building have?
(Note:
Are
you currently insured?
Select One
Yes
No
Have
you file any claims in the past 3 years
Select One
Yes
NO
Are
you currently insured?
Select One
Yes
No
If
yes, what company?
Expiration
date
How
soon are you looking to start your insurance?
Select One
Now, assuming a good price
1 week
2 weeks
1 month or more
What
is the approximate amount you pay commercial auto insurance
now?
What
is the approximate amount you pay for property insurance
now coveraged
What
limit of liability do your want?
Select One
500.000
1.000.000
2,000,000
3,000,000
5,000,000
Do
you want your contents covered
Select One
Yes
No
If
yes, how much coverage do you want your contents covered
for?
Additional
information your agent should know
