Le Claire Insurance

J L Le Claire & Sons Insurance Agency

The Protection and Security you would expect from Family

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Complete the following information if you would like to obtain an Office and Business Owner Insurance quote. Please understand this is not an application. All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.
Personal Information
What is your name?	Last
	First
	Middle
What is your business name?	Business Name
What is your address?	Street
	City
	State
	Zip
What is your telephone number?	Home
What is your telephone number?	Business
What is your fax number?	Fax
What is your email address?	Email
Underwriting Information
What is the nature of your business?	Nature of Business
Is the business a corporation, partnership or sole proprietorship?	Corporation Partnership Sole Proprietorship
How many owners?	Number of Owners
How many employees?	Number of Employees
What is the payroll amount of the owners?	Payroll of Owners
What is the payroll amount of the employees?	Payroll of Employees
What is the total annual gross?	Total Annual Gross Receipts
What is the business license number?	Business License Number
What is the license type?	License Type
Years of experience in this business?	Years of Experience
How many years have you operated under your current business name?	Years Operated Under Current Name
Have you used any other business names during the past 5 years?	Other Business Names	Yes No
Is this business open 24 hours a day	Open 24 Hours	Yes No
Any deep frying (food)?	Deep Frying	Yes No
If so, is there an Ansul or equivilant extiguishing device installed?	Ansul system	Yes No
Is there any manufacturing, mixing, re-labeling or repackaging of products?	Manufacturing	Yes No
Is there filling of propane tanks?	Propane Tank Filling	Yes No
Please describe the nature of your business and ANY unusual exposures.	Unusual Exposures
Building & Property Information
What is the total square footage of the building your business is in?	Total Square Footage of Business Building
What is the total square footage of your business only?	Total Square Footage of Business Only
What is the square footage of the customer area only?	Square Footage of Customer Area
How many stories is it?	Stories
If it's two stories, what is the ground floor square footage?	Ground Floor Square Footage
What is the construction type?	Construction Type
What type roof covering?
Was the roof updated?	Roof Updated	Yes No
If yes, what year?	Year Roof Updated
What is the distance of fire protection?
Is the business in a brush area?	Brush	Yes No
Do you have a storage area more than 1500 Sq. Ft.?	Storage Area more than 1500 sq. ft.	Yes No
Are there smoke detectors at this location?	Smoke Detectors	Yes No
Are there fire extinguishers?	Fire Extinguishers	Yes No
Are there deadbolts on all doors?	Deadbolts	Yes No
Are there circuit breakers?	Circuit Breakers	Yes No
Is the electrical updated?	Electrical Update
If yes, what year was the electrical updated?	Year of Electrical Update
Is the heating/ air conditioning thermostatically controlled?	Thermostatically Controlled	Yes No
Is the heating/ air conditioning central?	Central	Yes No
Has the plumbing been updated?	Plumbing Updated	Yes No
If yes, what year was the plumbing updated?	Year of Plumbing Update
Does the building have interior automatic fire sprinklers?	Automatic Fire Sprinklers	Yes No
Is there a theft alarm?	Theft Alarm	Yes No
Is there a fire alarm?	Fire Alarm	Yes No
Are there any restaurants in your building	Restaurants in the building	Yes No
Are there any restaurants in the building next to your business?	Restaurants Next to Business	Yes No
Claims Information
Where there any losses or claims in the last 5 years?	Losses - Claims	Yes No
If yes, what is the date, amount paid and description of each loss or claim?
Coverage Information
What is the current insurance company?
How much are you paying now?	Current Premium
What is the liability limit requested?	Liability Limit
What is the building limit requested?	Building Limit
What is the building deductible requested?	Building Deductible
What is the business personal property (contents) limit requested?	Business Personal Property Limit
What is the contents deductible requested?	Contents Deductible
What is the loss of income requested?	Loss of Income Coverage Limit

Comments/Additional Information/Additional Coverage Required: