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About Your Business
Sole Proprietor Partnership Corporation LLC Association
Do you currently have Business Owners insurance? Yes No
If "Yes", when does your current policy expire?
If YES, who are you currently insured with?
Type of Business
Description of Business Operations:
Year Business Established
Years at Current Location
Do you own or lease office space Own Lease Neither
Number of Locations
Number of Employees
Number of Company Vehicles
Approximate Annual Gross Revenue
Approximate Total Company Payroll
Approximate Amount of Desired Insurance
Approximate Square Footage of Occupancy
Approximate Square Footage of Entire Building
Have you been named in a lawsuit in the last year? Yes No
If "YES", briefly explain:
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Optional coverage (check the ones you may want)
Group Health Business Owners Workers Compensation Commercial Auto/Truck Business Liability Business Property Malpractice Errors and Ommissions Other
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Any Comments / Questions?
