Business Insurance Quote

General Information:  (Items marked * are required)
Contact Name  *
E-mail  *
Business Name
Address
City
State
Zip
County
Business Phone  *
Fax

Current Insurance Company (not the agency's name)
Company Name
Policy Expiration Date

Current Insurance Coverages
Bond Disability
Commercial Auto Group Health
Commercial Liability Group Life
Commercial Property Professional Liability
Commercial Umbrella Workers' Compensation
Directors & Officers Liability Other

About Your Business
Number of full-time employees
Number of part-time employees
How many years in business
How many locations
Please give a brief description of your business and clientele

Information about Location 1

Street Address
City/State Owner     Tenant
Year Built     % Occupied     Building Value $      Contents $
Construction Type      Stories      #Basements      Square Footage
  Burglar Alarm Yes   No Sprinklers? Yes   No
Other Property ( Specify)  

Information about Location 2

Street Address
City/State Owner     Tenant
Year Built     % Occupied     Building Value $      Contents $
Construction Type      Stories      #Basements      Square Footage
  Burglar Alarm Yes   No Sprinklers? Yes   No
Other Property ( Specify)  

Information about Location 3

Street Address
City/State Owner     Tenant
Year Built     % Occupied     Building Value $      Contents $
Construction Type      Stories      #Basements      Square Footage
  Burglar Alarm Yes   No Sprinklers? Yes   No
Other Property ( Specify)  

Liability
Class of Business If other:
Annual Gross Sales(before taxes)
Number of employees
Annualized Payroll
Cost of any Subcontracted Work
Limits Requested $300,000 $500,000 $1,000,000 $2,000,000
Describe any claims you've  
had in the past 5 years  
Additional Comments  


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Keuler Insurance Agency, Inc.
222 High St.
Mineral Point, WI 53565
Office: 608-987-2832
Fax: 608-987-3023
Toll Free: 888-987-2021
e-mail: kkeuler@keulerinsurance.com