Complete the following information if you would like to obtain a commercial Insurance quote. Remember, this is not an application, one will be sent to you if coverage is requested. All information provided on this information sheet is confidential and will be used solely for the purpose of quoting your commercial insurance.
Personal Information
What is your name?	Last
	First
	Middle
What is your business name?	Business Name
County Information	County
What is your address?	Street
	City
	State	Texas
	Zip
What is your telephone number?	Home
	Business
What is your fax number?	Fax
What is your email address?	Email
Confirm your email address?	Email
Underwriting Information
What is the nature of your business? Required	Nature of Business
Is the business a corporation, partnership or sole proprietorship?	Corporation Partnership Sole Proprietorship
How many owners?	Number of Owners
How many employees?	Number of Employees
What is the payroll amount of the owners? Required	Payroll of Owners
What is the payroll amount of the employees? Required	Payroll of Employees
What is the total annual gross? Required	Total Annual Gross Receipts
What is the business license number?	Business License Number
What is the license type?	License Type
Years of experience in this business? Required	Years of Experience
How many years have you operated under your current business name?	Years Operated Under Current Name
Have you used any other business names during the past 5 years?	Other Business Names	Yes No
Is this business open 24 hours a day	Open 24 Hours	Yes No
Please describe the nature of your business and ANY unusual exposures.	Unusual Exposures
Building & Property Information
What is the total square footage of the building your business is in?	Total Square Footage of Business Building
What is the total square footage of your business only?	Total Square Footage of Business Only
What is the square footage of the customer area only?	Square Footage of Customer Area
How many stories is it?	Stories	Select 1 2
If it's two stories, what is the ground floor square footage?	Ground Floor Square Footage
What is the construction type?	Construction Type	Select Brick Stone Frame Masonry Superior Log Cabin Frame-Stucco Masonry Veneer
What type roof covering?	Select Architectural shingles Asphalt/Fiberglass shingles Built-up/Tar and gravel Clay tile Concrete tile Corrugated steel Mineral fiber shakes Mission Tile Rock roof Roll roofing Rubber roof Slate Tin Wood fiber shingles Wood shake
If yes, what year?	Year Roof Updated
What is the distance of fire protection? Select 1000 ft or less to hydrant & 5 mi or less to fire station Over 1000 ft to hydrant & 5 MI or less to fire station Over 5 & up to 10 MI to fire station Over 10 MI to fire station
Is the business in a brush area?	Brush	Yes No
Do you have a storage area more than 1500 Sq. Ft.?	Storage Area	Yes No
Are there smoke detectors at this location?	Smoke Detectors	Yes No
Are there fire extinguishers?	Fire Extinguishers	Yes No
Are there deadbolts on all doors?	Deadbolts	Yes No
Are there circuit breakers?	Circuit Breakers	Yes No
Is the electrical updated?	Electrical Update	Select Yes, Recently Updated No
Is the heating/ air conditioning thermostatically controlled?	Thermostatically Controlled	Yes No
Is the heating/ air conditioning central?	Central	Yes No
Has the plumbing been updated?	Plumbing Updated	Yes No
If yes, what year was the plumbing updated?	Year Plumbing Update
Does the building have interior automatic fire sprinklers?	Automatic Fire Sprinklers	Yes No
Is there a theft alarm?	Theft Alarm	Yes No
Is there a fire alarm?	Fire Alarm	Yes No
Are there any restaurants in your building	Restaurants	Yes No
Are there any restaurants in the building next to your business?	Restaurants Next to Business	Yes No
Claims Information
Where there any losses or claims in the last 5 years?	Losses - Claims	Yes No
If yes, what is the date, amount paid and description of each loss or claim?
Coverage Information
What is the current insurance company?
How much are you paying now?	Amount Current Coverage
What is the liability limit requested?	Liability Limit	Select $100,000 $300,000 $500,000 $1,000,000
What is the building limit requested?	Building Limit
Do you require Coverage for the building?	Yes/No
What is the building deductible requested?	Building Deductible	Select 1% $250 $500 $1,000 $2,500
What is the business personal property (contents) limit requested?	Business Personal Property
Do you require Coverage for the business personal property?	Yes/No
What is the contents deductible requested?	Contents Deductible	Select 1% $250 $500 $1,000 $2,500
What is the loss of income requested?	Loss of Income Coverage
Are there any questions, comments or additional coverage required?	Questions, Comments or Additional Coverage

When is the best time to contact you.
	Morning Afternoon Evening Anytime

I currently have insurance
Yes  No