Please fill out this form completely to receive your quote:
Personal Information
Name (required):
Business Name
Street Address:
City
State:
Zip Code:
E-mail Address (required):
Phone Number:
Fax Number:
Underwriting Information
Nature of your Business:
Type of Business:
How many Owners?
How Many Employees?
Payroll Amount of Owners?
Payroll Amount of Employees?
Total Annual Gross:
Business License Number:
Years of Experience in this Business:
Years under current Business Name:
Have you used other business names? Yes       No
Are you open 24 hours a day? Yes       No
Any deep frying (food)? Yes       No
Is there manufacturing, mixing, relabeling, or repackaging of products? Yes       No
Is there filling of propane tanks? Yes       No
Describe ANY unusual exposures your business may have:
Building and Propoerty Information
What is the total square footage of the building your business is in?
What is the total square footage of your business only?
What is the square footage of the customer area only?
How many stories is it?
If it's two stories, what is the ground floor square footage?
What is the construction type?
What type roof covering?
If roof was updated, what year?
What is the distance of fire protection?
Is the business in a brush area? Yes       No
Do you have a storage area more than 1500 Sq. Ft.? Yes       No
Are there smoke detectors at this location? Yes       No
Are there fire extinguishers? Yes       No
Are there deadbolts on all doors? Yes       No
Are there circuit breakers? Yes       No
Is the electrical updated?
Is the heating/ air conditioning thermostatically controlled? Yes       No
Is the heating/ air conditioning central? Yes       No
Has the plumbing been updated? Yes       No
If yes, what year was the plumbing updated?
Does the building have interior automatic fire sprinklers? Yes       No
Is there a theft alarm? Yes       No
Is there a fire alarm? Yes       No
Are there any restaurants in your building Yes       No
Are there any restaurants in the building next to your business? Yes       No
Claims Information
Where there any losses or claims in the last 5 years? Yes       No
If yes, what is the date, amount paid and description of each loss or claim?
Coverage Information
What is the current insurance company?
How much are you paying now?
What is the liability limit requested?
What is the building limit requested?
What is the building deductible requested?
What is the business personal property (contents) limit requested?
What is the contents deductible requested?
What is the loss of income requested?
Are there any questions, comments or additional coverage required?
Best Time to Contact You
Please let us know the best time to call and discuss your quote.
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The Reinard Insurance Agency, Inc.
349 Bustleton Pike
Feasterville, PA 19053 (Directions)
Ph: 215-357-8600
Fx: 215-357-8061