SMALL BUSINESS INSURANCE

To help us supply you with the most accurate quote possible, please answer as many questions as you can with the most accurate information available to you.

Information submitted will be held confidential and will be used for quote purposes only. Submission of application information in no way obligates you to purchase any product or insurance, nor does it represent any agreement to provide coverage under any insurance policy.

BUSINESS INFORMATION

First Name:
Last Name:
Name of Business:
E-mail address:
Daytime Phone Number:
Evening Phone Number:
Fax Number:
How would you prefer to be contacted regarding your quote?	Phone Fax Mail E-mail
If you would prefer to be contacted by phone, please let us know the best time to call.	AM PM
Address:
City:
State:
Zip code:
Years in Business:
Policy Period:

Individual

Partnership

Corporation

Joint Venture

Other

LOCATION TO BE INSURED INFORMATION

Address:

City:

State:

Zip code:

Interest of premises:

	Owner		Owner/Lesser		Service
	Office		Habitational

Program:

	Retail		Wholesale		Service
	Office		Habitational

Description of Operations:

Mortgagee Name & Address:

LIMITS OF INSURANCE and OPTIONAL COVERAGES

Building:
Replacement Cost:	$
Actual Cash Value:	$
Construction: Frame:
Jointed Masonry:
Masonry: Noncombustable:
Fire Resistive:
Sq. foot are of each building:
Sq. foot area occupied by applicant:
Year of Construction:
Number of Stories:
Business Personal Property:
Deductible:
Exterior Glass
Sign
Money & Securities ($10,000 Inside/$2,000 outside):
Systems Breakdown / Boiler & Machinery
Accounts Receivable:
Valuable Papers:
Business Computer: Hardware:
Software:
Employee Dishonesty:
Business Liability:
Additional Insured Name Address:
Non-owned hired automobile:	Yes No
Annual sales:
Annual payroll:

3 YEAR PRIOR CARRIER

Policy #	Expiration Date:	Premium:
Policy #	Expiration Date:	Premium:
Policy #	Expiration Date:	Premium:

LOSS HISTORY

Date of loss:	Loss description:	Amount:
Date of loss:	Loss description:	Amount:
Date of loss:	Loss description:	Amount:

REMARKS

Quotation Forms


Auto	Home	Life	Business

	3109 East Tatman Court, Suite 101, P.O. Box 17068, Urbana, IL 61802 Phone: (217) 328-1612 Fax: (217) 328-1616 www.sticklen-ins.com
	E-mail: jsticklen@sticklen-ins.com