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101

 

Executive Suites Association Insurance Quote Form



General Information
Your Name:
Your Company:
Address:
City:   State:   Zip:
Business Phone:   Fax Number:
E-mail Address:

Current Insurance Information
Company Name:
Policy Exp. Date:  
Types of coverage you currently have:
Bonds
Auto
Property & Liability 		Workers Comp
Directors & Officers
Group Life & Health		 Prof. Liability
Other

About Your Business
No. of full-time employees:
Years in business:
No. of part-time employees:
No. of locations:

Annual Sales:


Please give a complete description of your operations:

Property Questions
Age of building
or year built:
Type of building
construction:
Number of
stories:
Other
occupancies:
Square feet
you occupy:
sq. ft.
If the building is over 25 years old, please answer the following:

Year electricity was updated:

Is it on circuit breakers?:


YesNo
Year plumbing was updated:

Copper or galvanized plumbing?:


Copper   Galvanized  
Other:
Year building was last re-roofed:

Type of roofing material:


 

Protective Devices
Burglar Alarm?
Central station
or local alarm?
Name of
alarm company:
Is the building
sprinklered?
Are there
smoke detectors?
YN
   Central Station
  Local Alarm
YN
YN

 

Liability Questions
Please provide information on previous insurance carrier:
Previous Ins. Carrier:
Policy number:
Prior premium:
Policy renewal date:
$
Please provide information about your business:
Years in business:
Projected gross annual receipts:
Projected annual payroll:
$
$

 

Coverage Limits
Building:
Contents
(equipment, inventory, supplies, etc.):
Deductible:
Loss of Income:
$
$
$
Money and Securities:
Glass or signs:
General Liability Limit:
Non-owned & Hired
Automobile Liability:
Is liquor liability needed?
$
$
YesNo
YesNo
    If glass coverage is needed, please provide dimensions:
    Please list other coverages you may need:

 

Miscellaneous Information
Name of Additional Insured
(Landlord or vendor):
Mailing Address:
City:   State:   Zip:

 

Comments or Information


Please click the "Submit Quote" button to send your quote request.

No coverage is in effect until bound by an insurance carrier. This is a request for quotation only.

 

 
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Berger & O'Neal Insurance Group
10425 Old Alabama Road Connector, Suite 101
Alpharetta, Georgia 30022
770-442-0770 Toll Free 1-866-442-0770 Fax 770-442-0774