General Information
Contact Name*
Email*
Business Name
Address
City
State
Zip
County
Business Phone Number
Business Fax
Which local agency would you like to use?*
Please choose one. . . Gosline-Murchie Agency, Gardiner, ME Quirion Insurance Agency, Augusta, ME Pease Insurance Agency, West Rockport Vannah Insurance Agency, Waldoboro, ME Readfield Insurance Agency, Readfield, ME Richmond Insurance Agency, Richmond, ME Kristie Rowell Insurance Services, Hallowell, ME Cornerstone FInancial, Inc., ME RD Johnson Agency, Bethel, ME Erickson Bonding & Insurance Associates, Inc., Augusta, ME
Current Insurance Information (Not Agency)
Company Name
Expiration Date
Current Insurance Coverage
Current Coverage
Bond Commercial Auto Commercial Liability Commercial Property Commercial Umbrella Directors & Officers Liability Disability Group Health Group Life Professional Liability Workers' Compensation Other
Business Information
Full-Time Employees
Part-Time Employees
How many years in business?
How many locations?
Please provide a brief description of your business and your clientele.
Property/Premise Information
Occupancy Status
Owner
Tenant
Year Built
% Occupied
Sprinklers
Yes
No
Construction Type
Wood Stucco Masonry Vinyl Siding Aluminum Siding Other
Number of Stories
Number of Basements
Sq. Footage
Burgular Alarm
Building Value
Contents
Other Property (Please Specify)
Insurance Information
Other
Annual Gross Sales (before taxes)
Total Number of Employees
Annualized Payroll
Subcontractor Costs
Limits Requested
$300,000 $500,000 $1,000,000 $2,000,000
Describe any claims you have files in the past 5 years.
Additional Comments
* indicates required fields
Disclaimer Notice - The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.
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