Business owners quote request form

Mikkelsen Insurance Services

Information needed to quote Business Owners Insurance! Please complete all blanks. California Only! If you have any questions please call 800-444-3199. (Our Privacy Statement)

Applicant Information

Name:
Business Name:
Address:
City:	CA Zip code:
Phone:
E-mail address:
Years in business.:
Business Structure:	(Indiv. )(Corp. )(Partnership )
Annual Gross Revenues:
Annual Payroll:
Current Carrier:
Expiration date:

Limits and special needs:

Building/Premises Information

Building value if owned?
Tenant improvement value if leased?
Business Personal Property value?
Age of building?
Type of construction?
Total square feet of building?
Total square feet occupied?
Is building sprinkled?

Detailed description of business:

Additional Information

Please answer all questions (explain all yes answers below):	Yes	No
1. Is business open more than 15 hours per day?
2. Do employees use their own vehicles for conducting business?
3. Does owner/manager have 3 or more years experience in this business?
4. Is there adequate lighting and exterior lighting in front and back?
5. Do all exterior doors have double cylinder dead-bolt locks?
6. Is the premises protected by central station burglar alarm?
7. Does applicant keep more than $500 on the premises?
8. Are deposits made on a nightly basis?
9. Do you repackage any items under your own label?

Additional information:

Please be sure that all questions are answered before you press "SEND". If you prefer, print the form and fax it to 209-839-8632.