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PAMB Business Package Quote Form
 









 

 

 

 

Life, Health, and
Disability Quote

 

 

 

  

 

Contact Information
Business Name:
Contact Name:
Address:
City:
State:   Zip:
Business Phone:  
Fax:
E-mail Address:
Effective Date:

Property Information
1. Age of Building:
  If over 20 years old, need year the following were updated:
  Plumbing:
  Heating:
  Wiring:
  Roof:
2. Square footage of Building:
3. Square footage of space occupied:
4. Building Construction:
5. Number of stories:
6. Basement? Yes No
7. Sprinklered? Yes No
8. Central Station Burglary Alarm System? Yes No
9. Central Station Fire Alarm System? Yes No
10. Perimeter Lighting? Yes No
11. Contents Limit:
12. Building Limit:
13. Computers valued at over $25,000? Yes No
  If Yes, value $
14.
Any Losses?
 

Workers Compensation
15. Are you incorporated? Yes No
  Fed ID#:
  If incorporated, do you wish to exclude the corporate officers?
Yes No
16. Gross Annual Payroll: $
  Any Workers Compensation Claims in the last 5 years?
Yes No
17. Number of employees:

Autos
1. Any corporate owned autos? Yes No
  If Yes, provide copy of current policy and list of drivers and their driver license numbers.

Additional Comments


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

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


 

    
 
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The Zutz Group is licensed to provide Property and Casualty Insurance in all states except AK and HI.
  
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