SCW Agency

Business Insurance

BUSINESS INSURANCE QUOTATION FORM

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.

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.

Business Information

First Name
Last Name
Name of Business
E-mail address
Daytime Phone Number
Evening Phone Number
Fax Number
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
Address
City
State
Zip code
Years in Business
Policy Period

Individual

Partnership

Corporation

Joint Venture

Other

Location to be Insured

Address

City

State

Zip code

Interest of premises

	Owner		Owner/Lesser		Service
	Office		Habitation

Program

	Retail		Wholesale		Service
	Office		Habitation

Description of Operations

Mortgagee Name & Address

Limits of Insurance and Optional Coverages

Building
Replacement Cost	$
Actual Cash Value	$
Construction: Frame
Jointed Masonry
Masonry: Non-combustible
Fire Resistive
Sq. foot are 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