Business Quote-Test - Russell Glatt Insurance Agency

Business Quote

 
* = Required Field
General Information
Contact Name *
Email *
Phone Number *
Business Name/Legal Name
Business Location Address
City
State
Zip/Postal Code*
County
Business Phone
Fax #
Business Information
Number of years in business
Number of Years in this profession  
Annual Gross Sales (or projected if new in business)  
Number of full-time employees  
Number of part-time employees  
Annual payroll  
Number of locations  
   
Brief description of your business & clientele


 		  
Seating capacity (if restaurant or pub)  
Cost of any subcontracted work  
   
Location/Premises InformationAddress



 
Current Coverages










 
Business Information
# of Full-Time Employees
# of Part-Time Employees
How long in Business? (yrs)
How many locations?
Please give a brief description of your business and clientele
Property/Premises Information
Address
Occupancy Status  
Year Built
% Occupied
Sprinklers  
Construction Type
Stories
# Basements
Sq. Footage
Burglar Alarm  
Building Value
Contents
Other Property (specify)
Insurance Information
Other
Annual Gross Sales: (before taxes)
Number of Employees
Annualized Payroll
Cost of any Subcontracted Work
Limits Requested


Describe any claims you've had in the past 5 years
Additional Comments
* = Required Field