11/20/2008 04:25:16 PM
70 Munroe Street Lynn, MA 01901 | Office: 781-599-2000 | Fax: 781-598-0170
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Business Insurance Quote
Name
Email
Business Name
Street Address
Street Address
City, State, Zip
Phone Numbers
Home
Work
Business Activities
1.
Type of organization
Corporation
Individual
Limited Liability Corp.
Non-Profit
Partnership
'S' Corporation
2. How many owners, partners, or officers?
3. How many employees, excluding owners,
partners or officers?
4. How many years have you been in business?
5. Last year's payroll:
6. This year's projected payroll:
7. Last year's gross sales:
8. This year's projected sales:
8. Describe your normal business activities
9. Have you had losses or claims in the past 5
years?
Yes
No
If yes, please give description, date and amount paid for each
Coverage Selection
Please indicate the desired coverage you would like quoted
.
General Liability
Crime
Property
Workers Comp
Equipment
Boiler & Machinery
Builder's Risk
Garage and Dealers
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