Independent Insurance Center / Firemark -- Technology Services Business Package Quote Form

Technology Services
Package
Insurance Quote We would like to provide you with a free, no-obligation insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

General Information
Name of Business:
Contact Name:
Email Address:
Mailing Address:
City:	State: Zip:
Business Phone:	Fax Number:
Location Address (type "same" if same as above):
City:	State: Zip:

Property Questions

Age of building
/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?:

Yes No

Year Plumbing was updated:
Copper or Galvanized plumbing?:

Copper Galvanized Other:

Year Building was last re-roofed:
Type of roofing material:

Type of heating system in the building:

Protective Devices

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

Y N Central Station
Local Alarm Y N Y N

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:

$ $

Describe your business, product or service:

Coverage Limits

Building: Contents (equipment,
inventory, supplies, etc.): Deductible: Loss of Income:

$ $ $

Money and Securities: Glass or signs: General Liability Limit: Non-owned and Hired
Automobile Liability: Any other liability required?

$ $ $ Yes No

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:

Additional Comments

Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough fields above, please enter them here.

Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.


Technology Services Package Insurance Quote		We would like to provide you with a free, no-obligation insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.

Property Questions
Age of building /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?:		Yes No
Year Plumbing was updated: Copper or Galvanized plumbing?:		Copper Galvanized Other:
Year Building was last re-roofed: Type of roofing material:
Type of heating system in the building:

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

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:
	$		$
Describe your business, product or service:

Coverage Limits
Building:	Contents (equipment, inventory, supplies, etc.):		Deductible:	Loss of Income:
$	$			$
Money and Securities:	Glass or signs:	General Liability Limit:	Non-owned and Hired Automobile Liability:	Any other liability required?
$	$		$	Yes No
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: