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Fill out the following form as completely as possible. Once you have completed the form, click the Submit button to send your information. Your request will be handled promptly.

Company Owner
First Name
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Last Name
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Primary Phone Number
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Alternate Phone Number
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E-Mail Address
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Company Information
Company Name
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Business Type
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FEIN
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Street
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City
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State / Province
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ZIP / Postal Code
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Year Business Established
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Gross Annual Sales
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Number of Employees
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Annual Employee Payroll
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Property Coverage
Occupancy
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Estimated Cost of Building Replacement
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Year Built
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Construction Type
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Square Footage of Location
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Roof Type
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Number of Stories Including Basement
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Business Personal Property Limits
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Employee Tools
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Garage Keepers (vehicles in the care custody or control of insured)
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Open Lot Coverage (owned vehicles for sale)
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Additional Information
Number of mechanics
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Towing
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What is the total value of the units you are towing?
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Number of dealer plates
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Number of lifts
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Customers provided cars
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Current Information
Current Insurance Provider
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Current Policy End Date
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/ /
Claims/Property Losses in Past 5 Years (Please Explain)
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Workers Compensation
Office payroll ($)
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Shop payroll ($)
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Outide sales payroll ($)
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Additional Comments
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How did you hear about us?
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Submission Validation
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Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

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