Saperstein Agency, Inc.

Professional Office
Package Program
Quote		 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. We will contact you when this is received to discuss your insurance needs more adequately.

General Information
Name of Insured:
Contact Name:     Position:
Address:
City:   State:   Zip:
Business Phone:   Fax Number:
Business WebSite Address: http://
*Email Address (Required):
How many locations
do you have:
What type of coverage's are
you interested in:

 

Property Questions

Age of building
/Year Built:

Type of building
construction:

Number of
stories:

Other
occupancies:

Square feet
you occupy:

sq. ft.

If the building is over 25 years old, please answer the following:
Year Electricity was updated:

Is it on circuit breakers?:

Yes   No
Year Plumbing was updated:

Copper or Galvanized plumbing?:

Copper   Galvanized   Other:

Year Building was last re-roofed:

Type of roofing material:

Type of heating system in the building:

 

Protective Devices

Burglar Alarm:

Central Station
or local alarm?:

Is the building
sprinklered?:

Are there
smoke detectors?:

Y   N

  Central Station
 Local Alarm

Y   N

Y   N

 

Liability Questions

Please provide information on current insurance carrier:

Current Carrier:

Premium Amount:

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:
    Do you own the building you occupy?: Yes   No

 

Coverage Limits

Building:

Contents (equipment,
inventory, supplies, etc.):

Deductible:

Loss of Income:

$

$

$

Money and Securities:

Exterior signs:

General Liability Limit:

Non-owned vehicles used in business:

Is liquor liability needed?

$

$

Yes   No

    If Glass Coverage is needed, please provide dimensions:

    Please list other coverage's you may need:

 

Please Answer the Following Questions
to enable us to serve you better

Please indicate your concern regarding your current insurance protection:
Price
Too Much Coverage
Too Little Coverage		 Insurance Company/Agency not familiar
       with your business or household need

How would you rate the service that your current agent/broker provides:
Excellent Adequate Poor

If you could change one thing about your current insurance protection, what would it be:

 

Additional Comments

Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough fields above, please enter them here.


Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.

   

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