QUICKQUOTE ONLINE APPLICATION

Property, General Liability, Auto, Workers Comp, Umbrella

 

YOUR COMPANY NAME:
HQ ADDRESS:
CITY:
STATE:
ZIP:
 
WEBSITE:
 
PHONE:
FAX:
 
CONTACT NAME:
E-MAIL ADDRESS:
YEARS IN BUSINESS OR EXPERIENCE:
NUMBER OF EMPLOYEES:
NUMBER OF CORP. OFFICERS:
FEIN:
DESCRIPTION OF BUSINESS
LIST MAJOR CLIENTS:
 
OBTAINED CUSTOMER CONTRACT: Yes No
OBTAINED INSURED FINANCIAL STATEMENTS: Yes No
 
GROSS REVENUES LAST YEAR: $
GROSS REVENUES EXPECTED THIS YEAR: $
NON U.S. REVENUES: $
TOTAL PAYROLL LAST YEAR: $
EXPECTED PAYROLL THIS YEAR: $
 
LOCATION 1:
ADDRESS:
 
AGE OF BUILDING:
NUMBER OF STORIES:
SQUARE FOOTAGE OCCUPIED:
SPRINKLER SYSTEM Yes No
OTHER FIRE SUPPRESSION:
BURGLAR ALARM: Yes No
TYPE:
MONITORED BY:
CONSTRUCTION OF BUILDING:
TOTAL REPLACEMENT VALUE OF THE BUSINESS PROPERTY: $
TOTAL REPLACEMENT VALUE OF THE COMPUTER EQUIPMENT: $
DO YOU OWN THE BUILDING?
IF SO, WHAT IS THE BUILDING REPLACEMENT COST: $
 
LOCATION 2:
ADDRESS:
 
AGE OF BUILDING:
NUMBER OF STORIES:
SQUARE FOOTAGE OCCUPIED:
SPRINKLER SYSTEM Yes No
OTHER FIRE SUPPRESSION:
BURGLAR ALARM: Yes No
TYPE:
MONITORED BY:
CONSTRUCTION OF BUILDING:
TOTAL REPLACEMENT VALUE OF THE BUSINESS PROPERTY: $
TOTAL REPLACEMENT VALUE OF THE COMPUTER EQUIPMENT: $
DO YOU OWN THE BUILDING?
IF SO, WHAT IS THE BUILDING REPLACEMENT COST: $
 
LIST OF EMPLOYEES BY JOB DESCRIPTION AND SALARY
(WORKERS COMPENSATION
JOB CLASS CODE SALARY (INCL 1099)
If you need a list and explanation of WC classifications please email us at Contact walkertaylorinsurance.com re: WC Classifications and we will email you a Word document.
 
UMBRELLA POLICY LIMITS REQUESTED:
DO YOU NEED ANY OF THE FOLLOWING: ($1,000,000 - $5,000,000)
 
PROFESSIONAL ERRORS AND OMISSION LIABILITY Yes No
MEDIA LIABILITY Yes No
DIRECTORS & OFFICERS LIABILITY Yes No
EMPLOYMENT PRACTICES LIABILITY Yes No
FIDUCIARY LIABILITY Yes No
CRIME (money, securities, employee dishonesty) Yes No
POLLUTION LIABILITY Yes No
AVIATION LIABILITY Yes No
INTERNATIONAL LIABILITY Yes No
KIDNAP RANSOM OR POLITICAL RISK Yes No
Email us if you need an explanation of any of the above at Contact walkertaylorinsurance.com
 
HAS ANY INSURER CANCELLED OR NON-RENEWED
ANY INSURANCE COVERAGE? Yes No
 
EXPIRING CARRIER:
EXPIRING PREMIUM:
ANY LOSSES IN THE LAST 3 YEARS? Yes No
IF YES, DESCRIPTION OF LOSS, INCLUDING DATE AND AMOUNT PAID:
DO YOU NEED RENTAL CAR PHYSICAL DAMAGE COVERAGE? Yes No
 
OWNED AUTOS:
 
YR:
MAKE:
MODEL:
VIN:
COST NEW:
USE:
GARAGING ADDRESS:
 
YR:
MAKE:
MODEL:
VIN:
COST NEW:
USE:
GARAGING ADDRESS:
 
YR:
MAKE:
MODEL:
VIN:
COST NEW:
USE:
GARAGING ADDRESS:
 
 

 

 


1430 COMMONWEALTH DRIVE
WILMINGTON, NORTH CAROLINA 28403
(910) 509-9000