| Please complete the following
information for Business Insurance if you would like to make the most of your insurance
policy. If you would like to receive quotes for any of our services, please complete
the information requested and either fax or copy and paste this form into an e-mail with
the completed information and send it to us at info@town-countryinsurance.com.
We will respond to your request as soon as possible. NOTE: You may also Download a pdf
version of this form for viewing and printing. Business Owner Worksheet
First Name: ___________________
Last Name: ___________________
Business Name: ___________________
Address: ___________________
City/Zip Code: ___________________
Phone Number: ___________________
Fax Number: ___________________
E-Mail Address: ___________________
Underwriting Questions
Property County: __________________
Nature of Business: __________________
Number of Owners: __________________
Number of Employees: __________________
Payroll of Owners: __________________
Payroll of Employees: __________________
Total Annual Gross Receipts: __________________
Total Square Footage of
Building your Business is in: __________________
Square Footage of your
Business Only: __________________
Years in Business: __________________
How Many Stories: 1,2,3,4,5
Construction Type: Frame, etc.
Roof Type: Comp Shingle, Asphalt Shingle, Metal, Tile
Yr. Roof was Updated: __________________
Are there Smoke Detectors? Yes or No
Smoke Alarm: Yes or No
Fire Extinguisher: Yes or No
Deadbolts on Doors: Yes or No
Circuit Breakers: Yes or No
Electrical Updated: Yes or No When:_____
Plumbing Updated: Yes or No When:_____
Automatic Fire Sprinklers: Yes or No
Theft Alarm: Yes or No
Fire Alarm: Yes or No
Losses/Claims for 5 Yrs. Yes or No When:______
Coverage Information
Current Insurance Carrier: __________________
Building Coverage: __________________
Other Structures Coverage: __________________
Business Contents Coverage: __________________
Loss of Income Coverage: __________________
Liability Limits Requested: $100,000, $500,000, $1,000,000 or $2,000,000
Policy Deductible: $100, $250, $500, $1000
Workers Compensation Quote
First Name: ___________________
Last Name: ___________________
Business Name: ___________________
Address: ___________________
City/Zip Code: ___________________
Phone Number: ___________________
Fax Number: ___________________
E-Mail Address: ___________________
Underwriting Questions
Nature of Business: ____________________
Number of Owners: ____________________
Number of Employees: ____________________
Payroll of Owners: ____________________
Payroll of Employees: ____________________
Payroll Detail Information
Class/Code Payroll Rate Annual Payroll
Employee Group 1
Employee Group 2
Employee Group 3
Employee Group 4
Employee Group 5
Miscellaneous Information
Yrs. in Business: ___________________
Current Insurance Company: ___________________
Current Annual Premium: ___________________
Loss Information
Losses/Claims in Last 5 Yrs. Yes or No: If yes, describe loss
Coverage Information
Liability Limits Requested: $1,000,000,
$2,000,000 or $5,000,000
If you would like to receive quotes for any of our services, please
complete the information requested and either fax or copy and paste
this form into an e-mail with the completed information and send it
to us at info@town-countryinsurance.com.
We will respond to your request as soon as possible.
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