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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Directors and Officers INSURANCE SECTION |
D & O 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 Employees: |
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Number of Partners/Execs on your board (paid): |
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Number of Volunteers on your board: |
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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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What types of
insurance are you seeking? Choose as many as you need. |
#1:
#2:
#3:
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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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