A.D. DERN INSURANCE AGENCY, INC.

BUSINESS OWNERS INSURANCE

QUOTE FORM

CUSTOMER INFORMATION *required fields in red

    
*Email Address
Home Telephone
*Applicant's First Name
Cell Telephone

*Business Name Type

*Business Telephone
Mailing Address
Fax Telephone
City State Zip
*Description of Business
*Location #1: Address *City *State *Zip *County
*Location #2: Address *City *State *Zip *County

CURRENT INSURANCE INFORMATION

Company Name

Policy Number
List Coverages per Existing Insurance Policy
LOCATION # 1
    
LOCATION # 2
  
A. Building
B. Business Personal Property
Deductible
Deductible
E. Business Liability
E. Business Liability

F. Medical Payments
F. Medical Payments
Name Landlord Additional Insured
Name Landlord Additional Insured

More Add'l Insureds

If Yes, how many?
More Add'l Insureds
If Yes, how many?
List Add'l Items Below
List Add'l Items Below
 
 

Credits Available for Business Owners Insurance
Alarm System? Monitored?
Sprinkler System in Building?
Claim Free for 3 Years?
Smoke Alarms & Deadbolt Locks?
Renewal Credit w/ Carrier 3 Yrs?
Security Building Credit?

BUILDING DESCRIPTION & RISK DETAILS

Building Year Built

Square Foot Area Occupied
 
SAFETY UPDATING OF BUILDING SYSTEMS
Total Building Square Foot Area
Building Construction
 
Year
Extent of Updating
Foundation Type
Foundation Bolted
 
Roof Type
Year of Roof
 
Plumbing
# of Stories
# of Units in Building
 
Heating
# of attached Garages
# of Carports
 
Roof
Basement
Air Conditioning
 
Paint
 
EQ Retrofitting

  • What is the business' Annual Gross Receipts?
  • Is Business conducted from a home office?
  • Is there a Restaurant in the Building?
  • Is there a safe on the premises?
  • Number of full time employees? . . . . Number of part time employees?
  • Do you have any owned commercial autos?
  • Do you manufacture any products? . . . If Yes, explaine
  • Do you sell any products under your own label? . . . . If Yes, explaine
  • Do you sell any products that are directly imported? . . . . If Yes, explaine
  • Is Location in a government building, airbase, military installation, or a commercial airport? . . . . . . . . . . . . . . . . . . . . If Yes, explaine

5 YEAR CLAIM HISTORY
Claim
Date of Claim
Type of Claim

Description of Claim
Amount of Claim Paid
1
2
3
4

Ever been canceled or non-renewed in past 5 yrs? yes no . . If yes, please explain

Have you ever had a Fire Claim in your life time? yes no . . If yes, please explain
Any existing or unrepaired damage? If yes, please explain

PERSONAL INFORMATION - See Privacy Statement

 
Owners Name

Birthdate mm/dd/year

SS # or TIN # (nodashes)
Filed Bankruptcy in past 7 yrs

Experience in this Business Yrs / Mos

Total Years Experience in Business
1
2
/
3
/
4
/

ADDITIONAL NOTES - Please Explain"Yes" Answers


 

I/We acknowledge submission of this information is to receive a price quote for insurance, and that NO INSURANCE IS INFORCE until a completed and signed application with payment has been accepted by A.D. Dern Insurance Agency, Inc. and according to any specific Insurance Company requirements.

I agree to the above terms