(541) 726-0555
Springfield, OR
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General Information
Contact Name
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Email
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Phone Number
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Type of Business
Business Name
Business Phone
Mailing Address
City
State
Zip/Postal Code
County
How did you find our agency?
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Social Media
Customer Referral
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Current Insurance Company
Company Name
FEIN #
Current Insurance Coverages
Bond
Commercial Auto
Commercial Liability
Commercial Property
Liquor Liability
Directors & Officers Liability
Disability
Group Health
Group Life
Professional Liability
Workers' Compensation
Other
Business Information
# of Full-Time Employees
# of Part-Time Employees
How long in Business? (yrs)
How many locations?
Please give a brief description of your business and clientele
Property/Premises Information
Address
City
State
Zip
Occupancy Status
Owner
Tenant
Year Built
% Occupied
Sprinklers
Yes
No
Construction Type
Frame
Brick Veneer
Stucco
Metal
Concrete
Stories
# Basements
Sq. Footage
Burglar Alarm
Yes
No
Building Value
Contents
Other Property (specify)
Insurance Information
Business Personal Property Amount
Annual Gross Sales: (before taxes)
If Liquor Liability Required-Gross Annual Liquor Sales?
Annualized Payroll
Cost of any Subcontracted Work
Liability Limits Requested
$300,000
$500,000
$1,000,000
$2,000,000
Describe any claims you've had in the past 5 years
Additional Comments
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