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Personal
Information
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| Please
give us your Name: First
Initial Last
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| Home
Address
Apt. |
| City
State
Zip Code |
| Home
Phone Number (
)
Work Number (
)
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Email: Enter
Email again:
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| Social
Security No.
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|
Business
Information
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|
Type of operation:
Interest
Type:
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Primary
Classification:
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Date of
incorporation/registration: Month: Year:
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Number of full-time employees:
Number of part-time employees:
(If Sole Proprietor enter 1)
(If none
please enter 0)
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Current
total annual revenue:
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Building
Information
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|
Year
built:
Number of stories:
Construction type:
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Does
your building have sprinklers?
Type
of parking:
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Is
the building leased or owned?
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Additional
Coverage
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Please list any scheduled personal property items or collectibles for which you need additional coverage. Please indicate the type and amount, for example, 'Computers $25,000.'
Description: Amount ($):
Description: Amount ($):
Description: Amount ($):
Description: Amount ($):
Description: Amount ($):
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Liability
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Deductible
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Please check off any additional coverage's/riders you want your policy to include.
|
Errors &
Omissions
Professional Liability
Surety Bonds
Fidelity Bonds
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Umbrella
General Liability
Workers Comp
Director & Officer
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Employment Practice
Product Liability
Business Interruption
Sexual
Harassment
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Insurance
Information
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Do you currently have business
insurance?
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If Insured, select current carrier:
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How long, in years, have you had coverage
with this company?
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In the past five years have you reported any losses for the property?
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If you have, were those claims:
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Miscellaneous
Information
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|
Please
provide any additional information you feel is
pertinent to the insurance coverage you need.
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Clicking
Submit will forward your responses.
A
Glades Insurance Representative will contact you
shortly.
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