Information Needed to Quote Business Liability

· Business Name: ______

· DBA: ______

· Contact Person: ______

· Phone Number: ______E-Mail:______

· Address: ______

· Website: ______

· Date Established: ______FEIN: ______

· Individual / Partnership / Corporation / LLC / Other: ______

· Current Liability Insurance in place: Yes / No

· If no, why not: ______

· Current Carrier: ______Expiration: ______

· Nature of Business: ______

· Describe Applicant’s experience in this type of business: ______

· Number of Employees: ______Annual Payroll: $______

· Gross Annual Receipts / Revenue: $______

· Desired limits of liability: $1 million / $2 million / other: $______

· Building Value: $______Business Property Value: $______

· Building Sq. Footage: ______Year Built: ____ # of Floors: ______

· Circle the following building features: Sprinkler System / Central Fire Alarm / Central Burglar Alarm

Netpay Insurance Services Inc. * 369 Van Ness Way #701 Torrance, CA 90501

Office: 310-783-0951 Fax: 310-783-0369