Cell Phone Store Intake Quote

Legal Company Name *

E-Mail *

Phone Number *

EIN *

Business Description

Business Address

Square Footage of Your Location

Mailing Address

Estimated Total Gross Receipts/Revenue

Estimated Payroll 1-2 or 1-20? Employees

Business Personal Property (Inventory, Computers, Furniture, Etc) Amount Needed to be Covered

# of Owners

Years in Business

Years of Experience in Your Profession

Scope of Work - What is it that your business does?

Desired Effective Date

Endorsements Needed

Blanket Additional InsuredBlanket Waiver of SubrogationPrimary Wording30 day notice of cancellationPer Project Aggregate

Tools and Equipment - includes all your tools and inventory

10002500500075001000015000200002500030000More leave in the End Notes

How many stories is your Location

123+

Do you need any other lines of business? Work Comp, Umbrella, Business Auto?

Digital Signature *

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I acknowledge that all of the material representations in this form are truthful and I am responsible for any material misrepresentations that I have input.