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BERG MARTIN
&
FEKETE
On-Line Business Insurance Quote Form
Please Fill Out Completely
General Information
Name
(Required)
First
Last
Email
(Required)
Phone Number
(Required)
Business Name
(Required)
Mailing Address
(Required)
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Business Phone
Business Fax
Current Insurance Company
Company Name
Current Insurance Coverages
Current Insurance Coverages
Bond
Commercial Umbrella
Professional Liability
Commercial Auto
Disability
Commercial Liability
Group Health
Workers Compensation
Commercial Property
Group Life
Check all that Apply
Business Information
# of Full-Time Employees
# of Part-Time Employees
Years in Business
How Many Locations
Description of Business and Clientele
Property Information
Address
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Occupancy Status
Owner
Tenant
Year Built
% Occupied
Sprinklers
Yes
No
Type of Construction
Frame
Brick Veneer
Stucco
Masonary
Metal
Other
Stories
# Basements
Square Footage
Burgler Alarm
Yes
No
Building Value
Contents Value
Other Property (Specify)
Insurance Information
Annual Gross Sales
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 (Last 5 Years)
Additional Comments
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