WORKERS' COMPENSATION INSURANCE QUOTE REQUEST

Contact Information

Applicant Name: Mailing Address: Entity: Individual Corporation Partnership Other

Location(s) Information

Location Address: (only if different from mailing) City: State:    Zip Code: Phone: Fax: Contact Person: Federal Employees' Identification Number (FEIN):

Rating Information

# Estimated Annual Payroll: # Full Time Employees: # Part Time Employees:

Please list owners/officers/partners below

Name Title Ownership(%) Include/ Exclude Remuneration Owner 1 Owner 2 Owner 3

Business Information

Nature of Business/ Description of Operations Hours of Operation: Years in Business: Provide Health Care: Yes     No Current Carrier: Current Policy #: Effective Date: How did you find out about us?

Please Note: We cannot bind coverage from this email. Coverage is bound after you receive an email or telephone call from one of our agency staff members.

OFFICE AND BUSINESS OWNER INSURANCE QUOTE REQUEST

Personal Information

What is your name? Last First Middle What is your business name? Business Name What is your address? Street City State Select Alaska Alabama Arkansas Arizona California Colorado Connecticut Washington, DC Delaware Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming Zip What is your telephone number? Home Business What is your fax number? Fax What is your email address? Email

Underwriting Information

What is the nature of your business? Nature of Business Is the business a corporation, partnership or sole proprietorship? Corporation Partnership Sole Proprietorship How many owners? Number of Owners How many employees? Number of Employees What is the payroll amount of the owners? Payroll of Owners What is the payroll amount of the employees? Payroll of Employees What is the total annual gross? Total Annual Gross Receipts What is the business license number? Business License Number What is the license type? License Type Years of experience in this business? Years of Experience How many years have you operated under your current business name? Years Operated Under Current Name Have you used any other business names during the past 5 years? Other Business Names Yes     No Is this business open 24 hours a day Open 24 Hours Yes     No Any deep frying (food)? Deep Frying Yes     No Is there any manufacturing, mixing, re-labeling or repackaging of products? Manufacturing Yes     No Is there filling of propane tanks? Propane Tank Filling Yes     No Please describe the nature of your business and ANY unusual exposures. Unusual Exposures

Building & Property Information

What is the total square footage of the building your business is in? Total Square Footage of Business Building What is the total square footage of your business only? Total Square Footage of Business Only What is the square footage of the customer area only? Square Footage of Customer Area How many stories is it? Stories Select 1 2 If it's two stories, what is the ground floor square footage? Ground Floor Square Footage What is the construction type? Construction Type Select Brick Stone Frame Masonry Superior Log Cabin Frame-Stucco Masonry Veneer What type roof covering? Select Architectural shingles Asphalt/Fiberglass shingles Built-up/Tar and gravel Clay tile Concrete tile Corrugated steel Mineral fiber shakes Mission Tile Rock roof Roll roofing Rubber roof Slate Tin Wood fiber shingles Wood shake If yes, what year? Year Roof Updated What is the distance of fire protection? Select 1000 ft or less to hydrant & 5 mi or less to fire station Over 1000 ft to hydrant & 5 MI or less to fire station Over 5 & up to 10 MI to fire station Over 10 MI to fire station Is the business in a brush area? Brush Yes     No Do you have a storage area more than 1500 Sq. Ft.? Storage Area Yes     No Are there smoke detectors at this location? Smoke Detectors Yes     No Are there fire extinguishers? Fire Extinguishers Yes     No Are there deadbolts on all doors? Deadbolts Yes     No Are there circuit breakers? Circuit Breakers Yes     No Is the electrical updated? Electrical Update Select Yes, Recently Updated No Is the heating/air conditioning thermostatically controlled? Thermostatically Controlled Yes     No Is the heating/air conditioning central? Central Yes     No Has the plumbing been updated? Plumbing Updated Yes     No If yes, what year was the plumbing updated? Year Plumbing Update Does the building have interior automatic fire sprinklers? Automatic Fire Sprinklers Yes     No Is there a theft alarm? Theft Alarm Yes     No Is there a fire alarm? Fire Alarm Yes     No Are there any restaurants in your building? Restaurants Yes     No Are there any restaurants in the building next to your business? Restaurants Next to Business Yes     No

Claims Information

Where there any losses or claims in the last five years? Restaurants Next to Business Yes     No If yes, what is the date, amount paid and description of each loss or claim?

Coverage Information

What is the current insurance company? Select 20th Century 21st Century Casualty AAA AEGIS AETNA A G Edwards AIG Alliance Allied Allstate American Family Insurance American Manufacturers Mutual American National General Amica Mutual Blue Cross Calfarm Charter Insurance CIGNA Civil Service Employees Clarendon National CNA Colonial Penn Company Not Listed Continental Country Companies Dairyland Don't know name Electric Farm Bureau Insurance Farmers Farmers Union Fidelity Guaranty Fireman's Fund First General GEICO Casualty Co. General Accident Grange Ins Assn Guaranty National Hanover Hartford Horace Mann John Hancock Kemper Liberty Mutual Lumbermans Mutual Metropolitan Insurance Midwest Security Millers Mutual Fire Mutual of Omaha Mutual of New York National Farm Bureau National General Nationwide New York Life Northwestern Pacific Pennsylvania General Progressive Providian Prudential Rural Insurance SAFECO Sentry Shelter State Farm Travelers Unigard USAA Viking Workmens Company Not Listed Don't know name How much are you paying now? Amount Current Coverage What is the liability limit requested? Liability Limit Select $100,000 $300,000 $500,000 $1,000,000 What is the building limit requested? Building Limit What is the building deductible requested? Building Deductible Select $250 $500 $1,000 $2,500 What is the business personal property (contents) limit requested? Business Personal Property What is the contents deductible requested? Contents Deductible Select $250 $500 $1,000 $2,500 What is the loss of income requested? Loss of Income Coverage Are there any questions, comments or additional coverage required? Questions, Comments or Additional Coverage