List Employee's Annual Payroll Here (if none, enter $0):
$
Insert # of Employees here:
Number of Employees driving vehicles at work:
Number of Employees that do NOT drive at work:
Number of Employees driving vehicles over 25 years old:
Number of Employees driving vehicle over 72 years old:
NOTE: List any drivers MVR Activity in remarks (tickets, accidents, etc.)
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):
Provide breakdown percentages:
Passenger %
Truck %
Off-the-Road %
Coverage Desired: (Check One Please)
Limits of Coverage I am Interested In:
$100,000
$300,000
$500,000
$1 Million
Medical Limit ($1000 or $5000):
Limit of business property needed:
$ property coverage
Limit of open lot (vehicles held for sale) coverage needed:
$ vehicle values
Limit of garagekeepers coverage (value of vehicles in possession):
$ garagekeeper limit
Comp & Coll. Deductibles ($250, 500, 1000 ):
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.)
Comments/Remarks:
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