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BUSINESS INSURANCE QUOTE for MDVA Members

We would like to provide you with a free, no-obligation insurance quote. Please provide as much information possible for the most accurate quote.This information will be kept confidential and will be used for quote purposes only.

Personal Information
Name of Business	*
Name of Insured	*
Address	*
City	*
State	*
Zip Code	*
Location Address	(type "same" if same as above)
City
State
Zip Code
Phone Number	*
Email Address
Fax Number
	* Required Field

Property Questions
Number of locations	if more than 3, skip to Liability Questions
Age of building/year of built	Location 1 ....Location 2 ....Location 3
Type of building construction	Location 1 Location 2 Location 3
Number of stories	Location 1 ....Location 2 .... Location 3
Other tenants in building	Location 1 ....Location 2 ....Location 3
Square feet you occupy	Location 1 ....Location 2 ....Location 3
If the building is over 25 years old, please answer the following:
Year electricity was updated	Location 1 ....Location 2 ....Location 3
Year plumbing was updated	Location 1 ....Location 2 ....Location 3
Year heating was updated	Location 1 ....Location 2 ....Location 3
Year building was last re-roofed	Location 1 ....Location 2 ....Location 3
Protective Devices	Location 1	Location 2	Location 3
Burglar Alarm	Yes No	Yes No	Yes No
Type of alarm system
Name of alarm company
Is the building sprinklered?	Yes No	Yes No	Yes No
Are there smoke detectors?	Yes No	Yes No	Yes No

Liability Questions
Please provide information on previous insurance carrier
Name of previous carrier
Policy number
Prior premium	$
Policy renewal date
Please provide information about your business
Years in business
Projected gross annual receipts	$
Projected annual payroll	$
Describe your business, product or service

Coverage Limits
	Location 1	Location 2	Location 3
Building	$	$	$
Contents (equipment, inventory, supplies, etc.)	$	$	$
Deductible	..	..	..
Loss of income	$	$	$
General Liability limit	..	..	..

Automobile Schedule
Number of vehicles	If more than 8, skip the rest of this section
Vehicle 1	Year Make Model Original Cost VIN #
Vehicle 2	Year Make Model Original Cost VIN #
Vehicle 3	Year Make Model Original Cost VIN #
Vehicle 4	Year Make Model Original Cost VIN #
Vehicle 5	Year Make Model Original Cost VIN #
Vehicle 6	Year Make Model Original Cost VIN #
Vehicle 7	Year Make Model Original Cost VIN #
Vehicle 8	Year Make Model Original Cost VIN #

Workers' Compensation
Number of Employees	#
	Location 1	Location 2	Location 3
Classes
Payrolls
Experience Modification Rating

Umbrella Liability
Umbrella Liability limit

Additional Comments

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