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OFFICE AND BUSINESS OWNER INSURANCE QUOTE REQUEST
Complete the following information if you would like to obtain an Office and Business Owner Insurance quote. Please understand this is not an application. An application will be sent to you if coverage is desired.
All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.
Personal Information
What is your name?
Last
First
Middle
What is your business name?
Business Name
What is your address?
Street
City
State
Zip
What is your telephone number?
Home
Business
What is your fax number?
Fax
What is your email address?
Email
Underwriting Information
What is the nature of your business?
Nature of Business
Is the business a corporation, partnership or sole proprietorship?
Corporation
Partnership
Sole Proprietorship
How many owners?
Number of Owners
How many employees?
Number of Employees
What is the payroll amount of the owners?
Payroll of Owners
What is the payroll amount of the employees?
Payroll of Employees
What is the total annual gross?
Total Annual Gross Receipts
What is the business license number?
Business License Number
What is the license type?
License Type
Years of experience in this business?
Years of Experience
How many years have you operated under your current business name?
Years Operated Under Current Name
Have you used any other business names during the past 5 years?
Other Business Names
Yes No
Is this business open 24 hours a day
Open 24 Hours
Yes No
Any deep frying (food)?
Deep Frying
Yes No
Is there any manufacturing, mixing, re-labeling or repackaging of products?
Manufacturing
Yes No
Is there filling of propane tanks?
Propane Tank Filling
Yes No
Please describe the nature of your business and ANY unusual exposures.
Unusual Exposures
Building & Property Information
What is the total square footage of the building your business is in?
Total Square Footage of Business Building
What is the total square footage of your business only?
Total Square Footage of Business Only
What is the square footage of the customer area only?
Square Footage of Customer Area
How many stories is it?
Stories
If it's two stories, what is the ground floor square footage?
Ground Floor Square Footage
What is the construction type?
Construction Type
What type roof covering?
Was the roof updated?
Roof Updated
Yes No
If yes, what year?
Year Roof Updated
What is the distance of fire protection?

Is the business in a brush area?
Brush
Yes No
Do you have a storage area more than 1500 Sq. Ft.?
Storage Area
Yes No
Are there smoke detectors at this location?
Smoke Detectors
Yes No
Are there fire extinguishers?
Fire Extinguishers
Yes No
Are there deadbolts on all doors?
Deadbolts
Yes No
Are there circuit breakers?
Circuit Breakers
Yes No
Is the electrical updated?
Electrical Update
Is the heating/ air conditioning thermostatically controlled?
Thermostatically Controlled
Yes No
Is the heating/ air conditioning central?
Central
Yes No
Has the plumbing been updated?
Plumbing Updated
Yes No
If yes, what year was the plumbing updated?
Year Plumbing Update
Does the building have interior automatic fire sprinklers?
Automatic Fire Sprinklers
Yes No
Is there a theft alarm?
Theft Alarm
Yes No
Is there a fire alarm?
Fire Alarm
Yes No
Are there any restaurants in your building
Restaurants
Yes No
Are there any restaurants in the building next to your business?
Restaurants Next to Business
Yes No
Claims Information
Where there any losses or claims in the last 5 years?
Losses - Claims
Yes No
If yes, what is the date, amount paid and description of each loss or claim?
Coverage Information
What is the current insurance company?
How much are you paying now?
Amount Current Coverage
What is the liability limit requested?
Liability Limit
What is the building limit requested?
Building Limit
What is the building deductible requested?
Building Deductible
What is the business personal property (contents) limit requested?
Business Personal Property
What is the contents deductible requested?
Contents Deductible
What is the loss of income requested?
Loss of Income Coverage
Are there any questions, comments or additional coverage required?
Questions, Comments or Additional Coverage
Best Time to Contact You
Please let us know the best time to call and discuss your quote.
Morning
Afternoon
Evening
Anytime
Or specify other:
     
 
Wm.Scott Carter Insurance Agency #0703360

1820 W Carson St. Ste 221 | Torrance, CA 90501
Phone 310-732-0023
Fax 866-234-0026
 
The purpose of this paragraph is to allow the agent to present a customized disclaimer notice. The notice may present the agent's state license and is optional and generated by the agent.

 
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