Garber Atlas Fries & Associates, Inc. - Auto Insurance Form

General Information
Contact Name *
Email *
Business Name
Address
City
State
Zip
Country
Business Number
Fax

Current Insurance Company
(not agency)
Company Name
Policy Expiration Date

Business Information
# of Full-Time Employees
# of Part-Time Employees
How long in Business? (yrs)
How many locations?
Please give a brief description of your business and clientele

Property/Premises Information
Address
Occupancy Status

Owner Tenant
Year Built
% Occupied
Sprinklers

Yes No
Construction Type
Stories
# Basements
Sq. Footage
Burglar Alarm

Yes No
Building Value
Contents
Other Property (specify)

Insurance Information
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

Disclaimer
* = Required Field

Disclaimer Notice - The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.
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