Commercial Property And Casualty Quick Quote Form
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1For the most accurate quote please complete the
below form in full.
Abram Interstate Insurance Services, Inc.
2211 Plaza Drive, Suite 100, Rocklin, CA 95765
Phone: 916.780.7000
Fax: 916.780.7181
Commercial Property & Casualty Quick Quote
(INDICATION ONLY*)
BROKER INFO
Date: _____/_____/____
Agency Name: _______________________________________ Contact: ______________________________
Address: _________________________________City_________________State_______________Zip______
Phone: (___) ____ - ______
Email: ______________________________
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Complete Named Insured: ____________________________________________ Phone: (___) ____ - ______
Doing Business as: _________________________________________________________________________
Mailing Address: _________________________________ City: _______________ State:____ Zip: _________
Location Address: _________________________________ City: _______________ State:____ Zip: ________
Currently Insured
Date Business Started: ____/____/_____
: Yes / No
Target Premium: _____________
Current/ Prior Carrier: _________________________________________ Expiration Date: ____/____/_______
Claims History: _____________________________________________________________________________
Entity Type:
Individual
Partnership
Corporation
LLC
Other
Coverage Desired:
WC
GL
PROPERTY
AUTO
UMBRELLA
Nature of business/ description of operation: ______________________________________________________
___________________________________________________________________________________________
Describe applicant's experience in operations (including # of years): ____________________________________
___________________________________________________________________________________________
# of Employees: __________ Annual Payroll: _______________ Gross Annual Receipts: _______________
Alcohol Receipts: ________________ Business Income: _______________
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L andlord
Additional Insured's Name: _________________________________
Property Information
!
L oss P ayee\Mortgagee
Building Value: _______________ Contents Value: _______________
!
O ther _ ____________
Deductible:
$500
$1000
$2500
$5000
Building Information
Sprinkler:
Yes
No
Safe:
Yes
No
Theft Alarm:
Yes
No
___________
Bldg Sq. Feet:
Occupied Sq. Footage: __________ Construction Type: ____________
Year Built: ________ # of Floors: ______
Update Year:
Roof _______
Plumbing_______
Heating_______
Electrical________
For Bars, Restaurants, Fast Food, and Nightclubs:
1) Major entertainment (DJ, live band, stage show)?
Yes
No
How many nights per week? ________
2) Is there Dancing?
Yes
No
3) Is there table seating?
Yes
No
Table service? Yes No
For Apartments: Annual rental receipts: ____________________________ Number of Units: __________
For Work Comp: Class code: _____________ FEIN____________
For Auto Repair Shops: Desired Garage Keepers Limit: ____________
# of Bays: ___________________
PLEASE EMAIL COMPLETED FORM TO OR FAX TO 916.780.7181
PRIOR
* Completed ACORD Application and/or Company Supplements required
to binding.
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