Business / Commercial Quote - Young & Haggis Insurance Services Ltd

General Information

Contact Name*

Email*

Business Name

Address

Street Address City State / Province / Region ZIP / Postal Code

Business Phone

Fax

Current Insurance Company

Company Name

Policy Expiration Date

Current Insurance Coverages

Current Coverages

Business Information

# of Full-Time Employees

# of Part-Time Employees

How long in Business? (yrs)

How many locations?

Please give a brief description of your business and clientele

Property/Premises Information

Address

Street Address

Year Built

% Occupied

Sprinklers

Yes
No

Construction Type

Stories

# Basements

Sq. Footage

Burglar Alarm

Yes
No

Building Value

Contents

Other Property (specify)

Insurance Information

Other

Annual Gross Sales: (before taxes)

Number of Employees

Annualized Payroll

Cost of any Subcontracted Work

Limits Requested

$1,000,000
$2,000,000
Over $2,000,000

Describe any claims you've had in the past 5 years

Additional Comments

Disclaimer Notice - The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.

Name

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