Business Owners/Commercial - Request for Proposal
 
Company Information:
Company Name:
Company Type:
Corporation Partnership Sole Proprietor Other
   
Mailing Address:
Address 1:
Address 2:
City: State: Zip:
   
Phone: FAX Number:
Email Address:
Website:
   
 
Property Schedule:
Location Building Limit Business Personal Property Loss of Income Other Square Footage
 
 
Construction Type: Wood Frame Concrete Masonry  
Type of Roof: Year Built:  
 
Protection (check all that apply):
Burglar Alarm Fire Extinguisher Sprinklers Other  
 
         
General Liability:
1 Million 2 Million Other    
   
         
 
Description of Operations:
   
 
Number of Employees: Full Part
Annual Sales: Annual Payroll:
       
 
Do you hire subcontractors: Yes No
 
If yes, do you obtain Certificates of Insurance?: Yes No N/A
 
Current Insurer:
 
         
Any claims the past 5 years?: Yes No
If yes, explain:
 
Any Additional Insured's: Yes No
Name:
Address:
Interest:
 
Description of your business:
 
   
 
 
 
License #: 0578496
Copyright Vicencia & Buckley Insurances Services Inc.
The information herein is for illustration purposes only and is designed as a general description of coverage's. Coverage will be determined by the actual policy language.
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