Texaspartnersinsurance

Complete the following information if you would like to obtain a commercial Insurance quote. Remember, this is not an application, one will be sent to you if coverage is requested.All information provided on this information sheet is confidential and will be used solely for the purpose of quoting your commercial insurance.

First Name:

Last Name:

Business Name

County

Street

City

State

Zip

Home

Business

What is your fax number? Fax

What is your email address? Email

Confirm your email address? Email

What is the nature of your business? Nature of Business

Is the business a corporation, partnership or sole proprietorship?CorporationPartnershipSole Proprietorship

How many owners? Number of Owners:

How many employees?:Number of Employees:

What is the payroll amount of the owners? Payroll of Owners:

What is the payroll amount of the employees? Payroll of Employees:

What is the total annual gross? Total Annual Gross Receipts:

What is the business license number? Business License Number:

What is the license type? License Type

Years of experience in this business?Years of Experience:

How many years have you operated under your current business name? Years Operated Under Current Name:

Have you used any other business names during the past 5 years? Other Business Names :YesNo

Is this business open 24 hours a day Open 24 HoursYesNo

Please describe the nature of your business and ANY unusual exposures. Unusual Exposures:

Building & Property Information

Year built:

Total Square Footage of Business Building:

Total Square Footage of Business Only:

Square Footage of Customer Area:

Stories:

Ground Floor Square Footage:

Losses - Claims: YesNo

If yes, what is the date, amount paid and description of each loss or claim?:

COVERAGE INFORMATION

What is the current insurance company?:

How much are you paying now? Amount Current Coverage:

What is the liability limit requested? Liability Limit:

What is the building limit requested? If no coverage is required for your building - Please type in N/A or 0 Building Limit

Do you require Coverage for the building? Yes/No

What is the building deductible requested? Building Deductible:>

What is the business personal property (contents) limit requested? Business Personal Property:

Do you require Coverage for the business personal property? Yes/No

What is the contents deductible requested?:Contents Deductible

What is the loss of income requested?:Loss of Income Coverage

Are there any questions, comments or additional coverage required?:Questions, Comments or Additional Coverage

When is the best time to contact you:MorningAfternoonEveningAnytime

I currently have insurance:YesNo

Texas CGL Form

Texas Commercial General Liability Insurance for Texas Based Businesses

Commercial General Liability Insurance

Building & Property Information

COVERAGE INFORMATION

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