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Friday	8:00 AM - 4:00 PM

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Daniels/Nicolson Insurance Agency, Inc. Business Quote

Business Quick Quote Request

General Information

Name of Business:

Entity Type:

Mailing Address:

City:

State:

Zip:

Contact Person:

Business Phone:

Business Fax:

Email Address:

Business Information
No. of full-time Employees	No. of part-time Employees	No. of Years in Business	Annual Sales	Annual Payroll

Please enter the name of business location(s) and related addresses:

Location #1:

Location #2:

Location #3:

Location #4:

Describe Your Business:

Current Insurance Company Information (not agency)

Current Insurance Provider (Company Name)

Premium Amount ($)

Policy Expiration Date:

(mm/dd/yy)

Three-year Loss History

Building Coverage

Building Limit:

Deductible:

Construction Type:

Ground Floor Dimensions:

(square feet)

Number of Stories:

Age of Building:

Do You Need Glass Coverage?

	Yes (If you checked YES, answer the orange questions below.)
	No (If you checked NO, skip the orange questions below.)

Total Linear Feet of Glass:

Total Square Feet of Glass:

Available Protective Devices:

	Central Fire
	Central Burglar
	Sprinkler
	Smoke Detectors
	Caretaker or Watchman on Premises
	Guard Dogs
	Ansul Systems

Business Personal Property Information

Current Limit:
Deductible:
	If separate limit for property off premises, indicate:

	If separate limit for computers, indicate:

	If separate limit for Time Element, indicate:

	If separate limit for Spoilage, indicate:

	Any other supplemental property coverages?

Auto Information

Coverage
UM/UIM Coverage
Medical
Comp Deductible
Collision Deductible

Make / Model	Year	VIN	Cost New
01.
02.
03.
04.
05.
06.
07.
08.
09.
10.

UMBRELLA Coverage

Select the amount of umbrella coverage you need:

Business Liability Information

Liability Needed:

Does Insured Deliver?

	Yes
	No

Are Employee Autos Used?

	Yes
	No

Check boxes to indicate a need for these optional coverages:

	Hired Auto Liability
	Employers Non-owned Auto Liability
	Professional Liability (If yes, indicate amount needed.)


	Garage Keepers (If yes, indicate amount of coverage needed.)

	Other (If checked, provide description.)

Quotes & Links

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Daniels/Nicolson Insurance Agency, Inc. Business Quote