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BOP Insurance Quote Form
 









 

 

 

 

 

 

  

 

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

Current Insurance Information
Company Name:
Policy Expiration 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:

No. of part-time employees:
Years in business:

Num. of locations:

Annual Sales:


Please give a complete description of your operations:


Property Questions
Age of building
or Year Built:
Type of building
construction:
Num. of
stories:
Other
occupancies:
Sq. feet
you occupy:
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:

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

Coverage Limits
Building:
Contents
(equip., inventory,
supplies, etc.):
Deductible:
Loss of Income:
$
$
$
Money and Securities:
Glass or signs:
Non-owned 
&S Hired
Auto Liability:
Is liquor liability needed?
$
$
Yes No
Yes No
General Liability Limit:
    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 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.