Janitorial (Commercial/Residential) Insurance Quote Form

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Company Name, Street Address, City, State, Zip Code
Phone Number
Fax Number
www.agencyname.com

* Denotes Required Field

General Information
*Business Name:
*Contact Name:	Position:
*Address:
*City:	*State: Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming   *Zip Code:
*Business Phone:	*Fax:   Ex. 920-555-1212
Business Status:	Select One Individual Corporation Partnership Joint Venture   Other:
Best Time to Call:	Select One Morning (8 a.m.-noon) Afternoon (noon-5 p.m) Evening (5 p.m.-9 p.m.)
Business Tax ID Number:
*Contact E-Mail Address:
*Confirm E-Mail Address:
*Location Address: (type "same" if same as above)
City:	State: Select One Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington, D.C. West Virginia Wisconsin Wyoming    Zip Code:

Current Insurance Information
Company Name (not agency):
Policy Expiration Date:	Ex. 01/15/2005
Premium Amount: $
Amount Insured For: $
Policy Type:	Select One Primary Secondary
Term:	6 Months 1 year Other

Limits of Liability
Limits of Liability Requested:
General Aggregate:	$	Each Occurrence:	$
Products & Completed Operations Aggregate	$	Fire Damage (any one fire):	$
Personal & Advertising Injury	$	Deductible:	$

Applicant / Employee Information
How long has the applicant been in business?:
Total number of employees:
Does the applicant have Workers' Compensation coverage in force?:			Select One Yes No
Does the applicant lease employees?:			Select One Yes No
Please describe the operations of the applicant (check all that apply):
Office Buildings		%	Apartment Buildings	%
Industrial Buildings		%	Hotels/Motels	%
Shopping Malls/Centers		%	Theaters/Movie Houses	%
Supermarkets/Dept. Stores		%	Hospitals	%
Retail Stores		%	Sports/Athletic Complexes	%
Terminals		%	Convention Halls	%
	Airport		Private Residences	%
	Railroad
	Bus
	Shipyard
Window Cleaning		Max. # of Stories	Scaffolds/Rigging	Rented/Owned Select One Rented Owned Both
	Contract with:
Annual PAYROLL Information:
Janitorial:		$	Owner:	$
Window Cleaning:		$	Employees:	$
Carpet Cleaning:		$
Floor Waxing:		$
Pool Service:		$
Other:		$
Annual SALES Information:
Janitorial:		$	Owner:	$
Window Cleaning:		$	Employees:	$
Carpet Cleaning:		$
Floor Waxing:		$
Pool Service:		$
Other:		$

Miscellaneous Information
Does risk store L.P.G., flammable liquids, ammunition, or explosives on the premises?:	Select One Yes No
If "Yes," please state the type and quantity stored:
Does risk lend, lease, or rent any equipment to others?:	Select One Yes No
If "Yes," state the type of equipment involved and the gross receipts derived therefrom:
Does the applicant subcontract work?:	Select One Yes No
If "Yes," please state the type of work that is subcontracted:
Are certificates of insurance required from all subcontractors?:	Select One Yes No
During the past three years, has any company ever cancelled, declined, or refused to renew similar insurance for the applicant?:	Select One Yes No

Previous Insurance
Year	Company	Policy #	Premium	Losses Paid	Losses Reserved	Description
			$	$	$
			$	$	$
			$	$	$
			$	$	$
			$	$	$

Additional Comments

Please provide any additional comments that you feel would be appropriate for this quotation. If you have additional information to provide, where there were not enough fields above, please enter it here

*Acknowledgment & Consent

I hereby certify that the above information is complete and accurate to the best of my knowledge. The agency receiving this application will retain the application whether or not a policy is issued. The agency may rely on this application when determining the quotation and when deciding whether to issue a policy. False statements may subject me to criminal penalties. If a policy is issued, I authorize the agency to give information about me to its affiliates. Yes No Enter your initials here:   Today's date: Ex. 01/15/2004

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