Business | The Hoffman Insurance Agency

General Information

Contact Name*(required)
Email*(valid email required)
____________________________________________
Business Name
Address
City
State/County
Business Phone
Fax

Current Insurance Company

(Not Agency)
Company Name
Policy Expiration Date

Current Insurance Coverages

Current Coverages

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

* = Required Field
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