Hollingsworth Insurance Services

 
Business Owners
Package (BOP)
Insurance Application		   We would like to provide you with a free, no-obligation insurance quote. Please provide as much information possible for the most accurate quote. This information will be kept confidential and will be used for quote purposes only.
 

Agent Information
* Required Field
* Agent Name:
* Phone #:   * Fax #:
* Email Address:
  (Note: A copy of this submision will be sent to the email
  address entered in this field, so please enter correctly)


General Information
* Required Field
* Name of Insured:
* Location of Risk:
* City:   * State:   * Zip:
* Insured's Phone:
* Type of Entity:
If Entity above is "Individual",
please give Owner's Name:
* Number of full time employees:       * Number of part time employees:
* Does insured have a web site?: Y N     If "Yes", http://www.
Mailing Address 
(if different from insured location):
City:   State:   Zip:
* # of Years in Business: * # of Years in Field: * Renewal/NB Date:
Current Insurance Carrier:   None
Current Insurance Renewal Date:   None

 
Property Questions
* Required Field
PROPERTY #1
(Location Listed in General Information section above)
*Actual Year Built:
*Type of building
construction:
*Number of
Stories in Building:
*Is Building
Sprinklered:
Y   N
*Total Square Feet
In Building:
*Total Sq. Ft. Occupied
by Insured/Owner:
*Central Station
Alarm Installed:
*If "yes", is it
(Alarm) Monitored:
Y   N
Y   N
If building is OLDER THAN 20 YEARS, please give last dates of updates to:
Roof:
Plumbing:
Heat:
Electrical:
 
PROPERTY #2
(If Applicable)
Location of Risk (Address, City/State/Zip):  
Actual Year Built:
Type of building
construction:
Number of
Stories in Building:
Is Building
Sprinklered:
Y   N
Total Square Feet
In Building:
Total Sq. Ft. Occupied
by Insured/Owner:
Central Station
Alarm Installed:
If "yes", is it
(Alarm) Monitored:
Y   N
Y   N
 

 
Liability Questions
* Required Field
Please provide information about your business:
*# of Years in Business:
*# of Years in Field:
*Liquor Liability:
Annual Liquor
Receipts:
Yes No
$
*Projected Gross annual receipts:
*Projected annual payroll:
% of Internet Sales:
$
$
*Describe your business, product or service
(specifically, what does risk do to earn money?):		 24 Hour Operation?:
Yes   No

 
Coverage Information
* Required Field
 
PROPERTY #1
(Same as Property #1 listed in Property Questions section)
Building:
*Business Personal Property (equipment,
inventory, supplies, etc.):
*If Liability
only, check
"None":
*Deductible:
*General Liability Limit:
$
$
None
 
PROPERTY #2
(If Applicable)
Building:
Business Personal Property (equipment,
inventory, supplies, etc.):
If Liability
only, check
"None":
Deductible:
General Liability Limit:
$
$
None

 
Loss Information
* Required Field
  Have there been any losses in the last 5 years?   Y   N     (if "Yes", please explain below)

 
Additional Comments
Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough fields above, please enter them here.


Please click on the "Submit Application" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.

   

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