Premier Services - The Insurance Experts

General Business Insurance Application
(Quotes will be provided for Pennsylvania, New Jersey, New York, Maryland and Delaware)

Contact name:

Company:

Address:

City, State, Zip Code:

County:

Phone:

Fax:

E-Mail:

Company Information

Type of business:

Number of locations:

Construction of building:

Sprinkers installed? Yes No

Are fire hydrants within 1000 feet? Yes No

Alarm system installed? Yes No

Approximate gross sales:

Approximate square footage or building:

Approximate square footage of area the business occupies:

Age of building:

Years in business:

Coverage information

Building amount:

Contents amount:

Liability amount:

Medical payment:

Glass - how much square footage:

Sign coverage amount:

Loss of earning:

Use this additional space for more information and for description of non business owners policy, business owners policy and type of business:

Current insurance carrier:

Effective date:

Premium paid:

Please explain any claims against you in the past five years. Please include date, amount of claim, and details:

Do you have quotations from other companies? Yes No

Would you like a quote from us for the same coverage for easy comparison? Yes No

Who is the insurance company?

What was the price quoted?

How did you hear about us?

Additional Comments: