Property and Casualty Insurance

Protection Advantage Liability Insurance Quote Form

Name:*

Company:*

Address:*

City:*

State:*

Zip:*

Phone:*

Email:*

1. Do you own or lease the building you are in?

Own Lease

If you own the building, what would be the 100% replacement cost new of your property?
$

If you lease the building or if you are the owner occupant,
what is the 100% replacement cost new of your:

Business Personal Property?
$

Office computer hardware and software
$

Office furniture and movable fixtures
$

Improvements and Betterments installed by you (rugs, flooring, shelves, etc)
$

Total*
$
(Note - Minimum value is $25,000 to cover your computer hardware software and media)

If you sub-lease any part of your premises to any other professionals or businesses, who are the tenants and what do they do?

2. What is your building's construction?

Frame (Walls and roof of wood or other combustible material) Brick (Walls of Brick or masonry - roof of wood or combustible material) Non-Combustible

(Walls of Brick or Masonry - and structure supported by steel - roof is made of steel deck or other non-combustible materials - your typical modern 1 or 2 story office building)

Fire Resistive

(Walls of Brick, Masonry, Cement or other non-combustible material – steel frame supports treated with fire-sesistive materials – Your typical hi-rise office building)

3. What is the total square footage of the building?
4. What is the total square footage you occupy?

5. Does the building have an automatic sprinkler system?

YES NO

6. What year was the building constructed?
7. How many employees do you have?
8. What is your annual payroll?

9. Do you currently carry Businessowners, Package or General Liability insurance?

YES NO

If YES, who is the insurance carrier and when does coverage expire?

10. Please list all property or general liability losses and claims you have incurred in the last 5 years.
(If none - please indicate)