Phone: (972) 235-3030
Toll-Free: (866) 900-RISK

Your Specialists

Brett Byland, ARM - EXT 110

Jerry Brunker - EXT 170

About 10 mins to complete application.

Get A Quote

PLEASE BE AWARE, in order for us to provide an accurate quote, ALL QUESTIONS must be answered. If you are unsure, please answer to the best of your knowledge.

Company Name:
Corporation Partnership
Sole Proprietor LLC Other
Mailing Address:

Number of Locations:
Discribe Nature of your Business::

Number of Employees and Payroll:
OWNERS: # of:



Gross Annual Revenue/Sales:

YesNo - Have you filed bankruptcy within the past 3 years?
YesNo - Do you have any ownership interest in any other businesses?
YesNo - Do you lease employees to or from other employers?
YesNo - Have any of your business insurance policies been declined, non-renewed or canceled in the last 3 years?
Do you have a current general liability policy? Yes No
If yes, have you had any claims or circumstances? Yes No

Property Information
  1. What is the total square footage of the building you occupy?
    Leased or Owned?
  2. Are there other occupants?
    Yes No
  3. What is the total square footage of your business only?
  4. How many stories is the building?
  5. If it is two stories, what is the ground floor square footage?
  6. What is the construction type?
  7. What type of roof covering?
  8. What is the distance of the nearest fire hydrant? Ft.
  9. What is the distance of the nearest fire department? Miles
  10. How old is the building?
  11. If the building is over 20 years old has the plumbing, electrical, roof and/or heating/AC been updated?
    Yes No
    --If yes, what year?
  12. Does the building have interior automatic fire sprinklers?
    Yes No
  13. Is there are theft alarm? Yes No -- Precentage of building protected %
  14. Is there a fire alarm? Yes No -- Precentage of building protected %
  15. Is there a sprinkler system?
    Yes No -- Precentage of building protected %
  16. Are there any property or general liability losses or claims in the last 5 years?
    Yes No
  17. If yes, what is the date, amount paid and description of each loss or claim?
Coverage Information
  1. What is your current general liability/property insurance company?
  2. What is your expiration date?
  3. Value of building, if owned?
  4. Value of office contents?
  5. Value of computer equipment & software?
  6. How frequently do you deposit cash to the bank?
  7. What is the maximum amount of money kept at your location overnight?
  8. Do you have any single pieces of tools and/or equipment valued more than $500?
    Yes No
    If so, list here:

Are you interested in quotes for any of the following?
Auto and/or Homeowners (renters) Insurance
Inland Marine (tools and equipment transported and stored on location)
Data Breach
Commercial Auto
Directors & Officers
Errors and Omissions/Professional Liability

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