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Business Name
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Current Coverages
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Business Information
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How long in Business? (yrs)
How many locations?
Please give a brief description of your business and clientele
Property/Premises Information
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Year Built
% Occupied
Sprinklers
Yes
No
Construction Type
Frame
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# Basements
Sq. Footage
Burglar Alarm
Yes
No
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
$300,000
$500,000
$1,000,000
$2,000,000
Describe any claims you've had in the past 5 years
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- The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.
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1296 Westgate Parkway
Dothan AL 36303
(334) 793-0014
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