Insurance Quote Request |
ABOUT THE OWNER / PRINCIPAL |
First Name:
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Last Name: |
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Address: |
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City: |
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State: |
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Phone: |
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Zip Code: |
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E-mail: |
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Confirm E-mail: |
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ABOUT THE BUSINESS |
Name
of Business: |
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Type of Business: |
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Description of Business: |
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Year Started: |
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Years experience in industry: |
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Tax ID # |
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CRIME INSURANCE SECTION |
CRIME
INSURANCE Liability Limits: |
$
($250,000 will be quoted if nothing is entered) |
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Full Time Employees: |
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Part-Time: |
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Number of Partners/Execs: |
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Number of Volunteers: |
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What
types of clients do you service: |
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Do you belong to
any professional associations? |
(if known) |
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Gross Receipts: |
Prior Year $
(if new business, write NEW and estimate an amount) |
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Current
Year $
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Estimates for Next
Year $
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Annual Payroll: |
$
(if none, write "none") |
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Claims: |
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Other: |
Do your customers sign a
contract or written agreement
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*** |
Do you currently have insurance (if
yes, with what carrier?
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Current Premium:
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Do you have any other information
about your business, or comments that you would like to
share? Please place special requests here, such as extra coverage
for special items. Do you conduct background checks on your
employees? |
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NO COVERAGE IS BOUND,
OFFERED, ISSUED THROUGH THIS ELECTRONIC COMMUNICATION, ALL POLICIES MUST BE
UNDERWRITTEN AND APPROVED BY THE CARRIER. DO NOT CANCEL YOUR CURRENT
INSURANCE. |
Copyright 2010 Stratum
Insurance Agency, LLC |
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