<%@LANGUAGE="JAVASCRIPT" CODEPAGE="1252"%>

Online Quote Questionnaire - Contact Information Business Name:   Contact Name:   Phone: Address: City: State:  Zip: Fax: Email: - Business Owners Insurance Quote Form Business Entity: Make Selection Sole-Proprietor Partnership Corporation LLC Business Type: Make Selection Retail Wholesale Manufacturer Current Carrier: Renewal Date: Any Losses: Make Selection No Yes Years In Business: Line of Business: Bridal % Tuxedo % Alterations Onsite: Make Selection No Yes Total Estimated Business Personal Property Replacement Cost: Definition: Business property including inventory, equipment, furniture, etc. utilized to operate business. $ Total Estimated Personal Property of Others: Definition: Any property of others in your care, custody and control. $ Total Estimated Annual Revenue: $ Do you have a Fire Sprinkler System: Make Selection No Yes Alarm System: Make Selection No Yes Type of Alarm System: Make Selection Central Local Year building was built: Year last renovated: Building Construction Type: Make Selection Frame Brick Concrete Wood Beams Steel Beams Metal Panels Fire-proofed Non-combustible materials Do you lease or own: Make Selection Lease Own Sqft. of Shop If You Own: Replacement value of building $ If You Own: Sqft. of Building Please Choose a Deductible Amount: Make Selection $250 $500 $1,000 $2,500 $5,000 Please Choose a Liability Amount: Make Selection $500,000 $1 Million $2 Million - Workers' Compensation Insurance Quote Form Federal ID: # Any Losses: Make Selection No Yes Current Carrier: Renewal Date: # of Full Time Employees: # of Part Time Employees: Annual Payroll Amounts for any that apply: Clothing Retail: $ Clerical: $ Tailoring: $ Outside Sales: $ Other: $ $ -

All rights reserved. © Copyright 2000 Capax - Giddings, Corby, Hynes Inc Lic#: 0144783