| Print - Complete - Fax for Commercial Quote Associates Insurance Network, LLC Email AssocIns2006@yahoo.com Today's Date ____/____/_______ Phone 985-224-1314 Fax 985-224-4145 Renewal Date ____/____/_______ Referred by __________________Phone # ________________ Fax# ____________ Business Name: _______________________ Description of Operations:_______________________ Owner: __________________ Tax ID or SS#______________________ BDay: ___/___/_____ M / F:__ Physical Address: _________________________ City: _______________ Zip Code_________ Mailing Address: __________________________ City: _______________ Zip Code_________ Phone: _(_____)________________ Ext._______ Fax: _(_____)_____________ Years in Business:___ Years Experience:___ Prior Insurance?___ Company:_________ Prem?______ COMMERCIAL PROPERTY*************************************************************************************** Bldg. Value Loan Amt?$______ Total Sq Ft:_____ Deductible$______ Contents Amount $________ Yr.Built:______ Construction Type?_________ Piers/Slab:______ Central Air/Heat?____ # Stories:___ Flood Ins?_____ Bankruptcy in 5 Yrs?___ Roof Type?_______ Yr Roof Replaced:______ Sprinkler?__ SmokeDet/DeadBolts/FireExt.?_____ Monitored or Local Alarm?_____ Other Coverage?___________ Any Losses in 5 yrs?____ Date:____/____/______ Type:______________________ Amt:$__________ COMMERCIAL AUTOMOBILE***************************************************************************** Veh#1 Year:_____ Make:______ Model:_________ VIN:__________________________ GVW:______ Veh#2 Year:_____ Make:______ Model:_________ VIN:__________________________ GVW:______ Liability Limits:____/____/_____ UM:____/____/____ Med Pay:_____ Hired/Nonowned Limit?________ Deductibles - Veh#1 Comp Coll Veh#2 Comp Coll Veh#3 Comp Coll Any Violations, Accidents or Claims in 5 years?_____ Date:___/___/_____ Type:______________ Attach driver list to include the following: Name, Home Address, DOB, SS#, License# and Driving Exp. OTHER COMMERCIAL****************************************************************************************** Workers Comp?____ # Owners/Officers__ # Employees__ Employee Payroll$_______ Code________ General Liability?__ Limits?_____ # of Employees____ Annual Payroll$______ Gross Receipts$_____ Other Information To provide an accurate quotation we request a few reports that verify driving records, prior losses, and insurance scores. This is the reason we request the Tax ID, Drivers License and SS#. |
| 985-224-1314 Associns2006@yahoo.com |
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