SMALL BUSINESS INSURANCE

To help us supply you with the most accurate quote possible, please answer as many questions
as you can with the most accurate information available to you.

Information submitted will be held confidential and will be used for quote purposes only. Submission
of application information in no way obligates you to purchase any product or insurance, nor does it represent any agreement to provide coverage under any insurance policy.


BUSINESS INFORMATION
First Name:
Last Name:
Name of Business:
E-mail address:
Daytime Phone Number:  
Evening Phone Number:  
Fax Number:
How would you prefer to be contacted regarding  your quote? Phone   Fax   Mail   E-mail
If you would prefer to be contacted by phone,
 please let us know the best time to call.		 AM   PM
Address:
City:
State:
Zip code:
Years in Business:
Policy Period:
Individual Partnership Corporation Joint Venture Other

LOCATION TO BE INSURED INFORMATION
Address:
City:
State:
Zip code:
Interest of premises:
Owner Owner/Lessor Service
Office Habitational    
Program:
Retail Wholesale Service
Office Habitational    
Description of Operations:
Mortgagee Name & Address:

LIMITS OF INSURANCE and OPTIONAL COVERAGES
Building:
Replacement Cost: $
Actual Cash Value: $
Construction: Frame:
Joisted Masonry:
Masonry: Noncombustable:
Fire Resistive:
Sq. foot area of each building:
Sq. foot area occupied by applicant:
Year of Construction:
Number of Stories:
Business Personal Property:
Deductible:
Exterior Glass
Sign
Money & Securities
($10,000 Inside/$2,000 outside):
Systems Breakdown / Boiler & Machinery
Accounts Receivable:
Valuable Papers:
Business Computer: Hardware:
Software:
Employee Dishonesty:
Business Liability:
Additional Insured Name Address:
Non-owned or hired automobile: Yes No
Annual sales:
Annual payroll:

3 YEAR PRIOR CARRIER
Policy # Expiration Date: Premium:
Policy # Expiration Date: Premium:
Policy # Expiration Date: Premium:

LOSS HISTORY
Date of loss: Loss description: Amount:
Date of loss: Loss description: Amount:
Date of loss: Loss description: Amount:

REMARKS

Quotation Forms


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Securities and advisory services offered through Wall Street Financial Group, Inc., Registered Investment Advisor, Member FINRA/SIPC Wall Street Financial Group, Inc. may only transact business in those states and international jurisdictions where we are registered/filed notice or otherwise excluded or exempted from registration requirements. Any communications with prospective clients residing in international jurisdictions where Wall Street Financial Group, Inc., and its registered representatives are not registered or licensed shall be limited so as not to trigger registration or licensing requirements. Insurance services from D. Robert Anderson may not be provided to individuals residing in any states other than NY. Insurance services from Spencer Corzine may not be provided to individuals residing in any states other than NY and VA. Insurance products are not offered through Wall Street Financial Group, Inc. Securities services from D. Robert Anderson may not be provided to individuals residing in any states other than CA, FL, GA, MD, NY, NC, OK, and VA. Securities services from Spencer Corzine may not be provided to individuals residing in any states other than CA, FL, GA, MD, NY, NC, OK, PA, SC, and VA. Advisory services from D. Robert Anderson may not be provided to individuals residing in any states other than CA, MD, NY, NJ, and FL. Advisory services from Spencer Corzine may not be provided to individuals residing in any states other than CA, MD, NJ, NY and FL. Wall Street Financial Group did not assist in the preparation of this material, and its accuracy and completeness are not guaranteed. The opinions expressed are those of the author(s) and are not necessarily those of Wall Street Financial Group, Inc. The material has been prepared or is distributed solely for informational purposes and is not a solicitation or an offer to buy any security or instrument or to participate in any trading strategy. Wall Street Financial Group, Inc. is not responsible for information contained on websites listed herein. Wall Street Financial Group, Inc., Anderson-Van Horne Associates, Inc., and companies with websites listed herein are all separate entities, independently owned and operated.Copyright 2003 © The Mines Press