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Personal Information |
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Please give us your
Name: First
Initial
Last
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Home Address
Apt.
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City
State
Zip Code
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Home Phone Number (
)
Work
Number (
)
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Email:
Enter
Email again:
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Social Security No.
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Business Information |
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Type of operation:
Interest Type:
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Primary Classification:
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Date of incorporation/registration: Month:
Year:
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Number of full-time employees:
Number of part-time employees:
(If Sole Proprietor enter
1) (If none
please enter 0) |
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Current total annual revenue:
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Building Information |
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Year built:
Number of stories:
Construction type:
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Does your building have sprinklers?
Type of
parking:
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Is the building leased or owned?
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Additional Coverage |
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Please list any scheduled personal property items
or collectibles for which you need additional coverage. Please
indicate the type and amount, for example, 'Computers $25,000.'
Description:
Amount ($):
Description:
Amount ($):
Description:
Amount ($):
Description:
Amount ($):
Description:
Amount ($):
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Liability
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Deductible
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Please check off any
additional coverage's/riders you want your policy to include.
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Errors
& Omissions
Professional
Liability
Surety
Bonds
Fidelity
Bonds |
Umbrella
General
Liability
Workers
Comp
Director
& Officer |
Employment
Practice
Product
Liability
Business
Interruption
Sexual
Harassment |
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Insurance Information |
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Do you currently have business insurance?
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If Insured, select current carrier:
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How long, in years, have you had coverage with this
company?
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In the past five years have you reported any losses
for the property?
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If you have, were those claims:
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Miscellaneous Information |
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Please provide any
additional information you feel is pertinent to the insurance coverage
you need.
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Clicking Submit will forward your responses.
An
Aabacoa Insurance Representative will contact you shortly. |