(541) 485-8437
Eugene, OR
Toggle navigation
Home
About Us
Request a Quote
Personal Insurance
Business Insurance
Customer Service
Report a Claim
Make a Payment Online
Change of Address
Evidence of Insurance
Request a Certificate
Blog
Contact
Farm Insurance Quote
General Information
Contact Name
*
Email
*
Phone Number
*
Type of Business
Business Name
Mailing Address
City
State
Zip/Postal Code
County
Business Phone
Fax
Current Insurance Company
Company Name
Current Insurance Coverages
Bond
Commercial Auto
Commercial Liability
Commercial Property
Liquor Liability
Directors & Officers Liability
Disability
Group Health
Group Life
Professional Liability
Workers' Compensation
Other
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
City
State
Zip
Occupancy Status
Owner
Tenant
Year Built
% Occupied
Sprinklers
Yes
No
Construction Type
Frame
Brick Veneer
Stucco
Metal
Concrete
Stories
# Basements
Sq. Footage
Burglar Alarm
Yes
No
Building Value
Contents
Other Property (specify)
Insurance Information
Business Personal Property Amount
Annual Gross Sales: (before taxes)
If Liquor Liability Required-Gross Annual Liquor Sales?
Annualized Payroll
Cost of any Subcontracted Work
Liability 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
Note: Coverage Can Not Be Bound Changed Or Deleted Via Electronic Message
© 2009-2024
Websites by Agency Relevance
, All Rights Reserved.
