J. Van Financial Group, PLLC. - Property Liability Quote

Property Liability Quote

Commercial Property Insurance Quote

Name of Business:
Contact Name:
Premises Address:
City:	State: Zip:
Business Phone:	Fax Number:
Contact Email Address:
Years in Business:
Description of Operations or SIC code(s):

Current Insurance Information

Current Insurance Carrier:

Premium: $ Expiration Date:

Annual Sales: $ Payroll: $ Business Income: $

Other Insurance Company Used Within Past 3 Years:
Policy #:
Losses past 3 years: Amount paid for each loss: $
Description of losses or loss runs:

Coverage's Desired

Liability Limit Desired: Deductible Desired:
Or choose other liability limit amount: $
Umbrella Amount Desired:

Building 1

Building Value: $ Contents Value: $
Total Building Area: Year Built:
Construction Type: Sprinklers:
Electrical Type: Amps:
Electrical Renovation Year:
Plumbing Renovation: Plumbing Renovation Year:
Heating Type: Heating Renovation Year:
Roofing Renovation: Roof Age (years):
Central Alarm:

List Neighboring Businesses:
To the right: Distance:
To the left: Distance:
To the rear: Distance:

Building 2

Additional Comments

Please give any additional comments or questions

No coverage of any kind is bound or implied by submitting information via this online form

Information from you and other sources, such as your driving, claims and insurance histories, may be used to calculate an accurate price for your insurance.
We will not distribute information to other parties other than for insurance underwriting purposes.
By submitting this form, you agree to release us from any liability should this information be accidentally viewed by others.

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