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Contact Name *
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(not agency)
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Current Coverages
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Please give a brief description of your business and clientele
Property/Premises Information
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Year Built
% Occupied
Sprinklers
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No
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# Basements
Sq. Footage
Burglar Alarm
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Building Value
Contents
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Insurance Information
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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
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Disclaimer Notice
- The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.
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Elena Kiselgof Insurance & Financial Services
398 Camino Gardens Blvd Suite 205
Boca Raton, FL. 33432
Call: (561) 544-1577
Fax: (561) 544-1675
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