Business Name:

Location Address:

City, State, Zip

Telephone:

Email Address:

Years in Business:

General Information

Current Carrier Information

Current Insurance Carrier

(not agent/broker):

Policy Expiration Date (mm/dd/yyyy):

Premium:

Term of Policy:

General Liability/Umbrella

Buidling Value:

Square Feet:

Construction Type:

Tools (under $1000/piece)

Alarm?

Driver Information

Name

Drivers License #

DOB(mm/dd/yy)

Limits/Deductibles

Current Liability Limit

Current Property Damage Limit

Comp. Deductible

Coll. Deductible

Towing

Rental

Medical

In the past 5 years has any driver listed had any:

Accidents:

Violations:

License Suspensions:

**Information received from this quote request form sent to A.L.S. Advisors, Inc. will be for

this request you acknowledge that this is neither an offer to insure nor a guarantee of

Insurance. No coverage is bound or implied by submitting this information.

Fed. ID #:

Contact Name:

Description of Operations:

Underwriting Information

Employees:

FT

PT

Estimated Annual Payroll:

Estimated Gross Sales:

Liability Aggregate Limit:

Umbrella Limit:

Property/Tools

Do you own the building you occupy?

Sprinkler?

Year Built::

Contents Value:

Tools (over $1000/piece)

Automobile Coverage

Vehicle 1

Vehicle 2

Vehicle 3

Year

Year

Year

Make & Model

V.I.N.

Make & Model

Make & Model

V.I.N.

V.I.N.

Please verify that the contact information above is correct as there may be

additional information required to provide an accurate, bindable quote.

Workers Compensation

Current Carrier:

Expiration Date (mm/dd/yyyy)

Exprerience Mod.

All quotes are subject to receipt of loss history and underwriter approval.

Code #

Class Description:

Payroll

Please use this space to explain any Liability, Property, Auto, or Workers Comp claim in the past 3 years:

Questions or Comments:

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