Davis and Madden Insurance

Business Package Insurance Quote

To receive a quote for Business Insurance, please provide us with the following information. Your current policy should have most of the information needed. All information submitted through this form will remain confidential. Our office will contact you or you may contact us.

Business Info

OWNER'S NAME:
BUSINESS NAME:
BUSINESS PHONE:
FAX PHONE:
EMAIL ADDRESS:
LOCATION ADDRESS:
CITY, STATE, ZIP:
BUSINESS TYPE/ DESCRIPTION:
TYPE OF OWNERSHIP:
NUMBER OF YEARS IN BUSINESS:
NUMBER OF YEARS EXPERIENCE:
TOTAL SQUARE FOOTAGE:
YEAR BUILT:
TYPE OF CONSTRUCTION:
SPRINKLERS:
IF YES WHAT PERCENTAGE?
DESCRIBE LOSSES IN LAST 5 YEARS:
GIVE DATES OF LOSS:
AMOUNT PAID:
DO YOU WANT COVERAGE FOR BUILDING:
YOUR BUILDING LIMITS:
BUSINESS PERSONAL PROPERTY LIMITS:
COMPUTER EQUIPMENT LIMITS:
LIABILITY LIMITS:
FIRE DAMAGE LIABILITY LIMITS:
MEDICAL PAYMENTS LIMIT:
EMPLOYEE DISHONESTY:	Amount:
THEFT OF MONEY:	Amount:
FOOD SPOILAGE LIMIT:
TRANSIT LIMIT:
Please list any additional comments you feel would help us:

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