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Michael W. Smith Agency

Revised:

May 06, 2015

Commercial

 763-535-7293

 

 

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Information

 

Please provide information on the type of business your company does.

Let me know about special concerns you have.

 

This is a request for a Minnesota commercial insurance quote, not a policy application. Submitting this form does not obligate you to purchase any commercial insurance products. Please complete this form as accurately as possible. Commercial insurance rates are subject to change.

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Contact Information

Contact Name
Company Name
Street
City, State ZIP

     

E-mail
Phone
Cell Phone
Fax
Web Address

Company Information

Form of Business
Years in Business
Years Experience in Business
Please describe your
business operations in detail
 

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Insurance Information

Effective Date Needed

Years of Loss Runs Available

Insurance Carrier Information
(if you have no previous insurance, enter "none" for the Year)

Year Carrier Policy Number Limits Premium

Loss History

Check here if no losses in the past 5 years

none

Please describe any losses you've had in the past five years.

Date of Loss Type of Loss Description of Loss Amount Paid Reserve

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Coverage's Requesting Quote On

Property General Liability
Business Auto Umbrella
Truckers Equipment
Garage/Dealers Electronic Data Processing
Transportation/Motor Truck Carrier Glass & Sign
Workers Compensation Boiler & Machinery
Accounts Receivable/Valuable Papers Crime
Installation/Builders Risk Bond
Kidnap & Ransom Employment Practices

Underwriting Questions

General Information

Explain all "Yes" responses Yes No Explain all "Yes" responses Yes No
Are you a subsidiary of another entity
or do you have any subsidiaries?
Any exposure to flammables,
explosives, chemicals?
Any operations sold, acquired,
or discontinued in last five years?
Have you been active in or are you
currently active in joint ventures?
During the past three years, has any
company ever cancelled, declined or refused
to issue any similar insurance to you?
Any bankruptcies, tax or credit liens
against you in the past five years?
Explain all yes responses

List anticipated gross sales for the current term
& sales for the past three years.

Year

Gross Sales

Current

20

20

20

Premises Information

Location #1

Address City State Zip Code
Year
Built
Interest Type of
Building
Construction
of Building
Responding Fire Department Miles to Fire Department Feet to Fire Hydrant

Location #2

Address City State Zip Code
Year
Built
Interest Type of
Building
Construction
of Building
Responding Fire Department Miles to Fire Department Feet to Fire Hydrant

Location #3

Address City State Zip Code
Year
Built
Interest Type of
Building
Construction
of Building
Responding Fire Department Miles to Fire Department Feet to Fire Hydrant

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Additional Comments


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Number of hits since August 15, 1998

 

 

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Copyright 2001, 2002, 2003, 2004, 2005, 2006, 2007, 2008, 2009 Michael W. Smith Agency