All City Insurance Agency

Business Insurance Quote

Please fill out form in it's entirety, then click "submit form"

General Information

Contact Name
E-Mail
Business Name
Address
City
State
ZIP
County
Business Phone
Fax

Current Insurance Company (not agency)

Company Name
Policy Expiration Date

Current Insurance Coverages

Bond
Commercial Auto
Commercial Liability
Commercial Property
Commercial Umbrella
Director & Officers Liability
Disability
Group Health
Group Life
Professional Liability
Worker's Compensation
Other

Business Information

Number of Full-Time Employees
Number of Part-Time Employees
How Long in Business (years)
Number of Locations
Please give a brief description of your business and clientele

Property/Premise Information

Address
Occupancy Status	Owner Tenant
Year Built
% Occupied
Sprinklers	Yes No
Construction Type
Number of Stories
Number of Basements
Square Footage
Burglar Alarm	Yes No
Building Value
Contents
Other Property (specify)

Insurance Information

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
Additional Comments

Auto Insurance Quote

Please fill out form in it's entirety, then click "submit form"

Insured Information

Insured Name
Address
City
State
ZIP
Phone
Date of Birth
Social Security Number
E-Mail Address

Current Insurance

Do you presently have Auto Insurance?	Yes No
Company Name
Renewal Date
Annual Premium
Have you been cancelled or non-renewed in the past 3 years?	Yes No

Coverages

Bodily Injury Liability
Property Damage Liability
Medical Payments
Uninsured Motorist Liability
Uninsured Motorist Property
Underinsured Motorist Liability
Underinsured Motorist Property
Comprehensive Deductible
Collision Deductible
Rental Reimbursement	Yes No
Towing & Labor	Yes No

Licensed Driver 1 (Primary)

Name on License
License State
License Number
Date of Birth
Gender	Male Female
Marital Status	Married Single Divorced Widowed
Relationship to Applicant
Occupation
Good Student	Yes No
Driver Training	Yes No
Tickets and Accidents (last 5 years)

Licensed Driver 2

Name on License
License State
License Number
Date of Birth
Gender	Male Female
Marital Status	Married Single Divorced Widowed
Relation to Applicant
Occupation
Good Student	Yes No
Driver Training	Yes No
Tickets and Accidents (last 5 years)

Other Drivers (any other residents in your household license to drive.)

Driver 1: Name
Driver 1: Date of Birth
Driver 1: Driver's License Number
Driver 2: Name
Driver 2: Date of Birth
Driver 2: Driver's License Number
Driver 3: Name
Driver 3: Date of Birth
Driver 3: Driver's License Number

Vehicle Information #1

Year
Make
Model
VIN
License State
Annual Mileage
# of Doors
4-Wheel Drive	Yes No
Alarm System	Yes No
Air Bags	Yes No
Anti-Lock Brakes	Yes No
Auto-Seatbelts	Yes No

Vehicle Information #2

Year
Make
Model
VIN
License State
Annual Mileage
# of Doors
4-Wheel Drive	Yes No
Alarm System	Yes No
Air Bags	Yes No
Anti-Lock Brakes	Yes No
Auto-Seatbelts	Yes No

Home Insurance Quote

Please fill out form in it's entirety, then click "submit form"

Policy Holder

Contact Name
Date of Birth
Social Security Number
E-Mail Address
Phone Number

Property Location

Address
City
State
ZIP
County

Current Insurance Information

Company Name
Current Annual Premium
Expiration Date
Deductible Desired
Amount of Liability
Earthquake Coverage Desired	Yes No
Have you filed for bankruptcy within the past 7 years?	Yes No

Dwelling Information

Estimated Replacement Cost
Square Footage
Year Constructed
How Many Floors?	1 Story 1.5 Story 2 Story Bi-Level Tri-Level Other
Type of Construction	Wood Stucco Masonry Brick Veneer Aluminum Siding Other

Other Features (check all that apply)

Dead Bolts
Smoke Detectors
Fire Extinguisher
Central Station Fire Alarm
Central Station Burglar Alarm
Home Located within 5 miles of Fire Station
Home Located within 1000 feet of a Fire Hydrant
Swimming Pool
Trampoline
Home located within City Limits

Claims - List any claims in past 3 years

Claim 1: Date
Claim 1: Amount Paid
Claim 1: Claim Type
Claim 1: Description
Claim 2: Date
Claim 2: Amount Paid
Claim 2: Claim Type
Claim 2: Description
Claim 3: Date
Claim 3: Amount Paid
Claim 3: Claim Type
Claim 3: Description

Personal Property (Estimated Value)

Jewelry & Watches
Furs
Silver
Firearms
Stamp and Coin Collections
Fine Arts and Breakable Items

Life Insurance Quote

Please fill out form in it's entirety, then click "submit form"

Life Insurance Information

Type
Amount of Death Benefit

Insured Information

Insured Name
Address
City
State
ZIP
Home Phone
E-Mail Address
Date of Birth
Use Tobacco	Yes No
Gender	Male Female
Height
Weight

Insured Medical Information

Describe any pre-existing Health conditions
List below any medication, including dosage and frequency
Note any other pertinent information or requests for coverage

Spouse Insurance Information

Spouse to be insured?	Yes No
Spouse Date of Birth
Spouse Use Tobacco	Yes No
Gender	Male Female
Height
Weight
Children	Yes No

Spouse Medical Information

Describe any pre-existing Health conditions
List below any medication, including dosage and frequency
Note any other pertinent information or requests for coverage

Children Information

Child 1: Date of Birth
Child 1: Gender	Male Female
Child 2: Date of Birth
Child 2: Gender	Male Female
Child 3: Date of Birth
Child 3: Gender	Male Female

Children Medical Information

Describe any pre-existing Heatlh conditions
List below any medication, including dosage and frequency
Note any other pertinent information or requests for coverage

Disability Insurance Information

Occupation
Duties
Earnings
Earnings Frequency	Weekly Monthly Yearly
Other Disability Coverage?	Yes No
Other Disability Coverage Type?	Individual Group

Disability Benefits to be Quoted

Elimination Period STD
Percentage Payable STD
Maximum Monthly Benefit STD
Duration of Benefits STD
Elimination Period LTD
Percentage Payable LTD
Maximum Monthly Benefit LTD
Duration of Benefits LTD