Mimosa Insurance Agency, LLC - Commercial Insurance Form

- Contact Name
- Email
- Business Name
- Address
- City
- State
- Zip
- County
- Business Phone
- Fax
- (not agency)
- Company Name
- Policy Expiration Date
- Current Coverages
  
  Other
- # 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
- Address
- Occupancy Status
- Year Built
- % Occupied
- Sprinklers
- Construction Type
- Stories
- # Basements
- Sq. Footage
- Burglar Alarm
- Building Value
- Contents
- Other Property (specify)
- Other
- Annual Gross Sales: (before taxes)
- Number of Employees
- Annualized Payroll
- Cost of any Subcontracted Work
- Limits Requested
- Describe any claims you've had in the past 5 years
- Additional Comments
- * = Required Field
  
  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.
- Should be Empty: