Business Quote - Rick Plata Insurance Agency

Business Quote

 
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General Information
Contact Name *
Email *
Phone Number *
Business Name
Mailing Address
City
State
Zip/Postal Code*
County
Business Phone
Fax
Current Insurance Company
Company Name
Current Insurance Coverages
Current Coverages



Liquor Liability
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
City
State
Zip
Occupancy Status  
Year Built
% Occupied
Sprinklers  
Construction Type
Stories
# Basements
Sq. Footage
Burglar Alarm  
Building Value
Contents
Other Property (specify)
Insurance Information
Business Personal Property Amount
Annual Gross Sales: (before taxes)
If Liquor Liability Required-Gross Annual Liquor Sales?
Annualized Payroll
Cost of any Subcontracted Work
Liability Limits Requested


Describe any claims you've had in the past 5 years
Additional Comments
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