Business Owners Policy

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Name:*   Email:*   Phone:   Year business started:*   How many years of experience does the owner of your business have in your industry?*   # of business vehicles: none 1-4 5-10 11-20 20+   Is your business for Profit or non-profit? profit non-profit   What is your business legal entity? Corporation S Corporation Limited Liability Company Limited Liability Partnership Partnership Sole Proprietorship Limited Partnership Professional Corporation Nonprofit Corporation   What industry is your company in? Office Retail Wholesale Manufacturing Trade   Detailed description of the nature of business:*   Are you currently insured? Yes No  If yes, what company?   Expiration Date: If currently insured, what is your annual premium range? $500 - 999 $1,000 - 2,999 $3,000 - 4,999 $5,000 - 9,999   $10,000 - 19,999 $20,000 - 49,999 $50,000+   Do you own or lease your office space? Lease Own   What type of property is your building? Office  Retail   Industrial Other:    Total square footage of your building:*   Total square footage of your space:*   Approximate year your building constructed:*   Which of the following features does your building have? (check all that apply) Sprinkler system Smoke detectors Burglary alarm Security guard Fire alarm  Exterior lighting Barred windows Circuit breakers Fuses None  Approximate amount of liability coverage needed: $1,000,000 $2,000,000 $3,000,000 $4,000,000 $5,000,000+  What is the deductible you would like for your property coverage? $250 $500 $1,000   $2,500 $5,000  # of Active Owners and/or Partners:* --Pick-- 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51+   # of Full Time Employees:* --Pick-- 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51+   # of Part Time Employees:* --Pick-- 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51+   # of Sub-Contractors:* --Pick-- 0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51+   When do you need coverage to start: *   Other information your agent should know:

For Insurance Purposes: This communication is strictly intended for individuals and businesses residing in the state of Washington.

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