| Business Name: |
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| Contact Name: |
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| Owner's Name: |
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| Address: |
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| Address Line 2: |
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| City: |
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| Zip Code: |
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| E-Mail Address: |
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| Phone: |
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| Fax: |
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| Contractor's License
Number: |
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| Date Business Started: |
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| Years Experience: |
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| Current Carrier: |
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| Expiration Date: |
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| Any Claims in Past 3
Years: |
Yes No |
| If Yes, Please List: |
|
Vehicles - List all vehicles to be
insured (Minimum 1 vehicle) |
|
Vehicles Section 2 (Continue information on each
vehicle for each vehicle number):
| # |
Value |
Use |
Radius |
Deductible
Desired |
| 1 |
|
|
|
|
| 2 |
|
|
|
|
| 3 |
|
|
|
|
| 4 |
|
|
|
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| 5 |
|
|
|
|
|
List ALL Drivers. Please include FIRST AND LAST names.
|
| If you
have more than 5 vehicles or drivers please include it in the Description of Operations
located below. If
vehicles are garaged at a different zip code than at the above location, please describe
in the business operations below. |
| Coverage Desired: |
|
| Bodily Injury/Property
Damage: |
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| Uninsured/Underinsured
Motorists - Bodily Injury (In Thousands): |
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| Uninsured/Underinsured
Motorists - Property Damge: |
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| Medical Payments: |
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| Desired Deductible: |
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| Comprehensive/Collision: |
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| Desired Effective
Date: |
|
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Please
Include a detailed description of business operations. Brief descriptions will slow
down the quoting process and require additional input from you.
Description
of Operations:
|
|
