The Hart Smith Company: Business Information Quotation Form

BUSINESS INFORMATION QUOTATION FORM

To help us supply you with the most accurate quote possible, please answer as many questions as you can with the most accurate information available to you.

Information submitted will be held confidential and will be used for quote purposes only. Submission of application information in no way obligates you to purchase any product or insurance, nor does it represent any agreement to provide coverage under any insurance policy.

Please note that completion of the following request for information does not constitute the purchase of insurance. No coverage may be added, changed or bound as a result of submitting this request for information or quotation of insurance. All coverage must be confirmed by the agency in writing subject to an acceptable signed application meeting the underwriting guidelines of the insurance company.

The Hart Smith Company is licensed in the state of Georgia. No solicitation of insurance is being made outside of this state.

Business Information
Your name
E-Mail address
Phone numbers				Daytime
				Evening
				Fax
How would you prefer to be contacted regarding your quote?				Phone Fax Mail E-Mail
If you would prefer to be contacted by phone, please let us know the best time to call.
Name of business
Company status
Business Location				Address City State, Zip
Years in business
Policy period
Interest of premises
Program
Description of operations
Mortgagee name & address
Limits of Insurance and Optional Coverages
Building
Replacement cost
Actual cash value
Construction
Sq. foot of each building
Sq. foot occupied by applicant
Year of construction
Number of stories
Business personal property
Deductible
Exterior glass
Sign
Money & Securities $10,000 Inside / $2,000 Outside
Systems breakdown / boiler & machinery
Accounts receivable
Valuable papers
Business computer				Hardware Software
Employee dishonesty
Business liability
Additional insured name & address
Non-owned & hired automobile
Annual sales
Annual payroll

3 Year Prior Carrier
Policy #	Expiration date	Premium
Policy #	Expiration date	Premium
Policy #	Expiration date	Premium
Loss History
Date of loss	Loss description	Amount
Date of loss	Loss description	Amount
Date of loss	Loss description	Amount
Remarks