SMALL BUSINESS INSURANCE

To help us supply you with the most accurate quote possible, please answer as many questions
as you can with the most accurate information available to you.  This agency is not licensed to procure insurance in all jurisdictions.  This web site should not be construed as a solicitation of any sort in any jurisdiction other than Virginia, North Carolina, Maryland, or West Virginia which are states in which we are licensed to transact business.

Information submitted will be held confidential and will be used for quote purposes only. Submission
of application information in no way obligates you to purchase any product or insurance, nor does it represent any agreement to provide coverage under any insurance policy.  There is no coverage in force until an application is approved and premium is received by an agent of the company.  False or misleading information with the intent to defraud or deceive may be subject to criminal prosecution for insurance fraud.

BUSINESS INFORMATION
Your name:
 First:   Last:
Name of business:
E-Mail address:
Address:
City:
State:
Zip code:
Years in business:
Policy period:
 Phone numbers:
Daytime:
Evening:
Fax:
How would you prefer to be contacted
regarding your quote?
 Phone     Fax     Mail    E-mail
If you would prefer to be contacted by phone,
please let us know the best time to call:
   am   pm
Individual:
Partnership:
Corporation:
Joint venture:
Other:
 
Location Address:
Street:
 
City:
 
State:
 
Zip code:
 Interest of premises:
Owner:
Program:
 Retail:
 
Owner/Lessor:
  
 Wholesale:
 
 Service:
  
 Service:
 
 Office:
 
 Office:
 
 Habitational:
  
 Habitational:
Description of operations: 
Mortgagee name & address:
LIMITS OF INSURANCE and OPTIONAL COVERAGES
Building:
Replacement cost:
$
Actual cash value:
$
Construction: Frame
Joisted masonry:
Masonry: Noncombustible:
Fire resistive:
Sq. foot area of each building:
Sq. foot area occupied by applicant:
Year of construction:
Number of stories:
Business personal property:
Deductible:
Exterior glass: 
Sign: 
Money & Securities
 $10,000 Inside/$2,000 outside:
Systems breakdown / boiler & machinery:
Accounts receivable: 
Valuable papers: 
Business computer: Hardware: 
Software: 
Employee dishonesty: 
Business liability: 
Additional insured name & address: 
Non-owned & hired automobile: 
 Yes No
Annual sales: 
Annual payroll: 
3 YEAR PRIOR CARRIER
Policy #
Expiration date:
Premium:
Policy #
Expiration date:
Premium:
Policy #
Expiration date:
Premium:
LOSS HISTORY
Date of loss:
Loss description:
Amount:
Date of loss:
Loss description:
Amount:
Date of loss:
Loss description:
Amount:
REMARKS