Countywide Insurance Agency - Business Owners Insurance Quote Form

Personal Information

	First Name:
	Last Name:
	Address:
	Address (Line 2):
	City:
	State:
	Zip:
	Business Phone:
	Fax:
	E-mail:
	Business Address:
	Business Address (Line 2):
	City:
	State:
	Zip:


Property Information

	Age of Building:
	Type of Construction:
	Number of Stories:
	Other Occupancies:
	Sq. Feet Occupied:

If the building is less than 25 years old, please skip the rest of this section

	Year Electricity was Updated:
	Is it on Circuit Breakers:	YesNo
	Year Plumbing was Updated:
	Plumbing Type:	CopperGalvanizedOther:
	Year Building was Re-Roofed:
	Type of Roofing Material:
	Type of Heating System:


Protective Devices

	Burglar Alarm:	YesNo
	Type of Alarm:	Central StationLocal Alarm
	Alarm Company:
	Does the Building have Sprinklers?:	YesNo
	Are there Smoke Detectors?:	YesNo


Liability Information

	Previous Insurance Carrier:
	Policy Number:
	Prior Premium:
	Policy Renewal Date:
	Years in Business:
	Projected Gross Annual Receipts:
	Projected Annual Payroll:
	Describe Your Business:


Coverage Limits

	Building:
	Contents:
	Deductible:
	Loss of Income:
	Money and Securities:
	Glass or Signs:
	General Liability Limit:
	Non-owned and Hired Automobile Liability:
	Is Liquor Liability Needed:	YesNo
	If Glass Coverage is Needed, Provide the Dimensions:
	Other Coverages Needed:


Miscellaneous Information

	Name of Additional Insured (Landlord or Vendor):
	Mailing Address:
	Mailing Address (Line 2):
	City:
	State:
	Zip:


Comments

If there is anything else we should know or if you didn't have enough space above please include it here: