Office Package policy

OFFICE PACKAGE

The form below is designed to gather enough information for us to provide you with a quick premium indication. We will provide you with quotes from our most competitive carriers.

BUSINESS OWNERS POLICY QUOTE SHEET

Named Insured*
Legal Entity: Individual Partnership Corporation Other
Effective Date
Mailing Address
Phone*:	Fax:	Email*:
Current Carrier & Premium

Underwriting Information

Location Address (if different from above)
Is this your home or office building	Office in home Office in building
Type of Business (Arch., Eng., Acct., Lawyer)
Construction of Building Frame Block Block w/ Steel Roof Fire-Resistive Other
Year Built
Central Station Monitored Alarm System?	Fire Burglar
Is there an operating sprinkler system?	Yes No
Are you the owner of building or tenant?	Owner Tenant

Coverage Information

Coverage Type	Limits
Building:	$
Business Contents:	$
Computer Equipment:	$
Computer Data/Media:	$
Valuable Records:	$
Accounts Receivable:	$
Money & Securities:
inside premises:	$
outside premises:	$

Employee Dishonesty (show separate amounts for each type)
regular coverage:	$
pension/welfare plan:	$

Any Equipment that leaves the premises?
(need list with make, model, serial #, value of each item)	$
Other Property Coverage(s):
General Liability
occurrence limit:	$
aggregate:	$
Hired & Non-Owned Auto Liability:	Yes No
Rental Car Physical Damage Coverage:	Yes No
Additional Insureds: - property lessors, equipment lessors? Show total number of A.I.'s needed	# of Addl. Insureds :
Employee Benefits Liability:	# of employees
Other: