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Contact Name:*
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Email:*
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Phone:
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Year started:*
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What is your business legal
entity?
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What industry is your company in?
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Detailed description of the nature of business:*
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How many years
of experience does the owner of your business have in your
industry? *
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Are you currently insured?
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Yes
No
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If yes, what company?
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Expiration
Date:
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What is your annual premium range?
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$500 - 999
$1,000 - 2,999
$3,000 - 4,999
$5,000 - 9,999
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$10,000 - 19,999
$20,000 - 49,999
$50,000+
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Do you own or lease your office space?
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Lease
Own
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What type of property is your building?
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Office
Retail Industrial
Other:
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Total square footage of your
building:
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Total square footage of your
space:
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Approximate year your building
constructed:
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Which of the following features
does your building have?
(check all that apply)
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Sprinkler
system
Smoke
detectors
Burglary
alarm
Security
guard
Fire alarm
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Exterior lighting
Barred windows
Circuit breakers
Fuses
None
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Approximate amount of
liability
coverage needed:
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$1,000,000
$2,000,000
$3,000,000
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$4,000,000
$5,000,000+
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What is the deductible you would
like for your property coverage?
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$500
$1,000
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$2,500
$5,000
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# of Active Owners and/or
Partners:*
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# of Full Time Employees:*
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# of Part Time Employees:*
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# of Sub-Contractors:*
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Other information your agent
should know:
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