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  Property Liability Insurance Quote
Full Name:  
Street Address:  
City, State & Zip:  
E-Mail Address:  
Day Telephone:  
Eve Telephone:  
Fax:  
Years in Business:
Description of Operations or SIC code(s):

*Please email or fax copies of current policies, declarations, 3 year loss runs, and any other available information.
 
 Current Insurance Information
Current Insurance Carrier:
Premium: $                          Expiration Date:   
Annual Sales: $            Payroll: $
Business Income: $
Other Insurance Company Used Within Past 3 Years: 
Policy #:
Losses past 2 years:
Amount paid for each loss: $
Description of losses or loss runs:
 
 Coverage Desired

Liability Limit Desired:      

Deductible Desired:
Or choose other liability limit amount: $
Umbrella Amount Desired:
 
 Building 1
Building Value: $                       
Contents Value: $
Total Building Area:          Year Built:
Construction Type:           Sprinklers:
Electrical Type:                         Amps:
Electrical Renovation Year: 
Plumbing Renovation:
Plumbing Renovation Year:
Heating Type:                                       
Heating Renovation Year: 
Roofing Renovation:                  Roof Age (years):  
Central Alarm:
 
List Neighboring Businesses:
To the right:   Distance:
To the left:     Distance:
To the rear:    Distance:
 
 Building 2
Building Value: $             
Contents Value: $
Total Building Area:        Year Built:
Construction Type:         Sprinklers:
Electrical Type:                       Amps:
Electrical Renovation Year: 
Plumbing Renovation:
Plumbing Renovation Year:
Heating Type:                
Heating Renovation Year: 
Roofing Renovation:              Roof Age (years):  
Central Alarm:
 
List Neighboring Businesses:
To the right: Distance:
To the left:   Distance:
To the rear:  Distance:
 
 Any additional comments or information that might be helpful in your quote:

No coverage of any kind is bound or implied by submitting information via this online form

Information from you and other sources, such as your driving, claims and insurance histories, may be used to calculate an accurate price for your insurance.

We will not distribute information to other parties other than for insurance underwriting purposes.

By checking the box below you agree to release us from any liability should this information be accidentally viewed by others.

 

YES! I Agree - By checking this box, you agree to release us from any liability should this information be accidentally viewed by others and you specifically agree that you are permitting any records to be run and reviewed in order to provide you with the best quotation including but not limited to accident loss history, motor vehicle record and credit.

 

 

 

(p) (828) 258-8030 ∙ (f) (828) 258-8030
(e) tony_johnson_agency@nationwide.com