Untitled Document
Untitled Document
TOW TRUCKS & TRUCKERS



Untitled Document



Contact Name:
Address:
City:
State/Providence
Zip/Postal Code
Phone:
Email:
Fax
Company Name:
Policy Expiration Date: (mm/dd/yyyy)
List type of coverages
Quote(s) needed for: Bond Commercial
Auto
Commercial Liability
Commercial Property
Commercial Umbrella
Directors & Officers Liability
Disability
Group Health
Group Life
Professional Liability
Workers Comp
Other

Business Information

  
# of Full-Time Employees
# of Part-Time Employees
How long in Business? (yrs)
How many locations?

Please give a brief description of your business and clientele

Property/Premises Information

Address
Occupancy Status
Year Built
% Occupied
Sprinklers

Stories
# Basements
Sq. Footage
Burglar Alarm
Building Value
Contents
Other Property (specify)

Insurance Information

 
Annual Gross Sales: (before taxes)

Number of Employees

Annualized Payroll

Cost of any Subcontracted Work

Limits Requested

Describe any claims you've had in the past 5 years
Additional Comments