| Commercial
Questionnaire |
| The following fields must be filled out completely and
accurately in order to obtain a quote. |
|
| Name of
contact person: |
|
| Name of
business: |
|
| Select
one: |
|
| Number
of locations: |
|
Any outside NC? |
Yes
No |
| Street: |
|
| City: |
|
| State: |
|
| Zip: |
|
| County: |
|
| Phone # (Include Area Code): |
|
| Fax # (Include Area Code) |
|
| E-mail: |
|
| How
would you like to be contacted? |
|
| Type of
business operation: |
|
| Number
of years in business: |
|
| Current
insurance carrier: |
|
| Exp.
date of current insurance policies: |
|
| Have you
had any losses or claims, regardless of fault, in the past three
years? |
Yes
No |
| Number
of vehicles: |
|
| Number
of employees: |
|
| Estimated
annual gross receipts: |
|
| Estimated
annual payroll: |
|
Total
estimated property value:
(buildings, contents, equipment, etc.) |
|
| Select
the coverage(s) you are interested in: |
Commercial
Property |
Umbrella
Liability |
|
General
Liability |
Employee
Benefits |
|
Workers
Compensation |
Contractors
Equipment |
|
Other
|
