Budd Agency Building

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Company Data:
*Your Name:
Your Company's Name:
Street Address:
City:
State:
Zip/Postal:
*E-Mail (REQUIRED):
E-Mail again for accuracy:
*Phone:
Fax (optional):
 
Currently Insured?
(If yes, list carrier, and # of years
continuous. If none, type NONE)
 
List Claims & Amounts Paid
(If none, type NONE)
 
Years In Business:
 
Business type:
(proprietorship, corporation, etc.)
 
Your Birthdate:
(Required for underwriting)
 
 
Underwriting Information:
 
Describe IN DETAIL,
Your Business Operations:
 
Ownership & Payroll Data:
List Employee's Annual Payroll Here (if none, enter $0): $ Insert # of
Employees here:
 
Location & Sales Information:
Insert Annual Gross Revenues from this operation here: $ Square Footage of office or business location:
 
Type of Building (wood frame, concrete, etc.): Number of Stories:
 
Are there other business/residences in this building (describe)?: Describe safety features (alarm, sprinklers, fire protection, etc):
 
Coverage Desired: (Check One Please)
The Coverage I Am Looking For:

Liability Only
Liability & Business Contents
Liability, Building & Contents Coverage
A Package Policy Including the Above, Plus Miscellaneous Coverages

 
Liability Coverage:
($300,000, $500,000, $1 Million, etc.) 		$
 
Business Contents Coverage:
(The amount of your personal business property) 		$
 
Building Coverage:
(The amount of building coverage if you own your bldg.) 		$
 
Miscellaneous Coverage:
(List any special coverage peculiar to your business, such as Garagekeepers Legal, Loss of Earnings, Valuable Papers, etc.) 		$
 
 


*Required

IMPORTANT NOTE: This website provides only a simplified description of insurance products and is not a statement of contract. Coverage cannot be bound through this online form. For more information please be sure to read the policy, including endorsements for complete details in coverage.