Agent Info:
Name : Denis Mehulic
License ID : 0L58079
Phone : (408) 674-3569
Email : [email protected]
Address : ste 201 1095, San Jose, California, 95136

Business Owners Policy

  • Applicant
  • Business
  • Business Location
  • Policy
  • Losses
  • Coverage
  • Miscellaneous
  • Finish

Applicant

First Name *
Last Name *

Where should we send your quote?

Email *
Phone *

Please fill all the mandatory questions.

Business

Business Info

Business /​ Company Name *
Years in Business *
DBA (If Applicable)
FEIN # (If Applicable)
Organization Type

Internal

Type of Business *
Additional Info
Number of Units *
Number of Swimming Pools /​ Jacuzzi *
Additional Info
Type of LRO *
Additional Info
What is the public area? *
Specific Business *
Annual Payroll *
Estimate Annual Income/Sales *
Description of Business

Please fill all the mandatory questions.

Business Location

Building Info

Business Address
Address *
City *
State *
Zip Code *
Construction Type
Roof Type
Other Roof Type
Total Square Feet
Year Built
Number of Stories
Number of Basement
Specify the Business

Building Renovations

Year Wiring was renovated
Year Heating was renovated
Year Plumbing was renovated
Year Roofing was renovated

Security

Burglar Alarm Type
Percent of Protection that is sprinklers
Type of Safety Program *

Please fill all the mandatory questions.

Policy

History

Reason for Cancellation
Type of Business
Please describe how or why are you using drones? *

Prior Carrier

Name of Carrier *
Policy Number *
Expiration Date of Policy *

Please fill all the mandatory questions.

Losses

loss 1

Loss Details

Type of Loss *
Date of Loss
Amount of Loss
Details of Loss

Please fill all the mandatory questions.

Coverage

Property Coverage

Building Limit *

(Sq ft. * Cost per Sq ft.)

Improvement and Betterment Cost
Deductible *
Business Personal Property
Personal Property of Other (If Any)
Loss of Income
Specify loss income/rent *

Additional Property Coverage

Liability Coverage

Occurrence /​ Aggregate
Product Liability

(Same as Aggregate Limit)

Liquor Classification *
Annual Liquor Sales *

Additional Policies

Umbrella Limit

Please fill all the mandatory questions.

Miscellaneous

Please fill all the mandatory questions.



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