For your convenience, you can click here to download this form. Then you can print, complete, and fax it back once you've gathered all the information required.

Business Name
Type of Business
Tax ID # (or owner's SSN)
Business Address
Mailing Address (if different)
Name of Business Owner(s)
Nature of Business (i.e. grocery store, carpet cleaner, general contractor, etc.)
Year business opened
Years of experience (that owner has in this industry)
Annual revenues
Number of Employees
Total annual payroll to employees
Is the building your business is in...	Owned Leased
Will the policy need to cover the building?	Yes No Not sure
If yes, what year was the building built?
If yes, how many square feet is the building?
Construction of building
What type of roofing does the building have?
Age of roof?
Is there a fire/theft alarm on the premises?	Fire Theft Both None
Any insurance claims in the last 5 years?	Yes No
If yes, please describe
If yes, what was the total dollar amount of the claim?
How much would it cost to replace ALL contents of the building? A rough estimate is fine.
Your Name
Direct Phone #
Email Address
Best Time To Contact You