Saperstein Agency, Inc.

REAL ESTATE
PACKAGE
PROGRAM		 We would like to provide you with a free, no-obligation Real Estate Package Program 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 Business:
Contact Name:     Position:
Address:
City:   State:   Zip:
Business Phone:   Fax:
Best Time To Call:   AM   PM
Business WebSite Address: http://
*Contact Email Address (Required):


Current Insurance Information
Insurance Company Name
(not agency):
Policy Expiration Date:   Premium Amount: $

What type of coverage's are you interested in?
Bond
Commercial Auto
Commercial Liability
Commercial Property		 Commercial Umbrella
Directors & Officers Liability
Disability
Group Health		 Group Life
Professional Liability
Workers' Compensation
Other  


About Your Business

# of employees

# of company
vehicles

How long
in business

How many
locations

Annual
sales

Annual
rental income

years

$

$


About Your Properties

Please give a brief description of the type(s) of property you own
(i.e. Office Buildings, Shopping Malls, Shopping Centers, etc...):

Please list each location, occupancy, value, and square footage of each property you own
(use the Additional Comments section at the end of this form if you have more than 5 properties):

 

Address
City,State/Zip

Occupancy

Building
Value

Square Footage

Do you occupy
this location?

 1 

$

Yes

 2 

$

Yes

 3 

$

Yes

 4 

$

Yes

 5 

$

Yes


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 space, 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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