(208) 322-3473 stan@hartleyonline.com

Quote Business

busquote_title

To help us supply you
with the most accurate quote possible, please answer as many questions

as you can with the most accurate information available to you.

Information submitted will be held confidential and will be used
for quote purposes only. Submission

of application information in no way obligates you to purchase any
product or insurance, nor does it represent any agreement to provide
coverage under any insurance policy.

 

BUSINESS
INFORMATION
Your name:
 First:

  Last:
Name of business:

E-Mail address:

Address:

City:

State:

Zip code:

Years in business:

Policy period:

 Phone
numbers:
Daytime:

Evening:

Fax:

How would you prefer
to be contactedregarding your quote?

Phone

Fax

Mail

E-mail
If you would prefer
to be contacted by phone,please let us know the best time to call:

am

pm
Individual:

Partnership:

Corporation:

Joint venture:

Other:

Location
Address:
Street:
City:
State:
Zip code:
 Interest
of premises:
Owner:
Program:
 Retail:
Owner/Lessor:
 Wholesale:
 Service:
 Service:
 Office:
 Office:
 Habitational:
 Habitational:
Description of operations:
Mortgagee name &
address:
LIMITS
OF INSURANCE and OPTIONAL COVERAGES
Building:
Replacement cost:
 $
Actual cash value:
 $
Construction: Frame

Joisted masonry:

Masonry: Noncombustible:
Fire resistive:
Sq. foot area of each
building:
Sq. foot area occupied
by applicant:
Year of construction:
Number of stories:
Business personal
property:
Deductible:
Exterior glass: 
Sign: 
Money & Securities$10,000 Inside/$2,000 outside:
Systems breakdown
/ boiler & machinery:
Accounts receivable: 
Valuable papers: 
Business computer:
Hardware: 
Software: 
Employee dishonesty: 
Business liability: 
Additional insured
name & address: 
Non-owned & hired
automobile: 

Yes

No
Annual sales: 
Annual payroll: 
3
YEAR PRIOR CARRIER
Policy #
Expiration date:
Premium:
Policy #
Expiration date:
Premium:
Policy #
Expiration date:
Premium:
LOSS
HISTORY
Date of loss:
Loss description:
Amount:
Date of loss:
Loss description:
Amount:
Date of loss:
Loss description:
Amount:
REMARKS


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