Canyon Insurance Agency :: Property & General Liability Quote

Type of quote:

Your full name: (required)

Business name: (required)

Business street address:

City, State & Zip:

E-Mail address: (required)

Day telephone: (required)

Eve telephone:

Fax:

Best time to reach you:

Do you have insurance now?

(if not, skip this section)

Insurance company name:

(not your agent or broker)

How long have you been insured with your current insurer?

(mm/dd/yyyy)

Annual premium amount:

Policy expiration date:

Policy number:

Any claims in the past 3 years?

If yes, how many claims?
Total amount of claims paid: $

Do you own or rent ?

Type of building construction:

Number of stories in building:

Are there other occupants?

Total square feet you occupy:

Is the building more than 25 years old?

(if newer than 25 years old, skip to ABOUT YOUR BUSINESS)

What year was the electricity updated?

If you do not know, check here:

What year was the plumbing updated?

If you do not know, check here:

Copper or galvanized?

Copper Galvanized Other:

What year was the roof last replaced?

If you do not know, check here:

Type of roofing material:

Type of heating system:

Is there a burglar alarm?

If YES, alarm company name:

What type of monitoring?

Are there smoke detectors?

Is the building sprinklered?

Number of years in business:

Number of locations:

Federal Tax ID Number:

Total square feet you occupy:

Projected gross annual sales:

Number of full-time employees:

Number of part-time employees:

Projected annual payroll:

Describe your business,
products or services:

Building:

Contents:
(Equipment, inventory, supplies, etc.)

Deductible:

Loss of income coverage:

Money and securities coverage:

Glass or signage coverage:

General liability limit:

Non-owned and hired auto liability limit:

Check all coverages you need:

Property and General Liability

Special Liability

Commercial Auto Liability

Liquor Liability

Do you offer safety programs?

Do you offer health benefits to the majority of your employees?

Do you employ any minors (under the age of 18)?

Do you use sub-contractors?

Do you use any equipment that bends, shapes or forms?

Are any athletic teams sponsored?

Has there been a lapse in coverage during the past 12 months?

Do employees ever work above 15 feet off the ground?

Has the business filed bankruptcy in the past 7 years?

Are you a member of any trade organizations?

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