AFFIRMATIVE INSURANCE SERVICES 5624 Lankershim Blvd., North Hollywood, Los Angeles, California-91601. Phone: 818-997-7879 Fax: 818-997-7844 EMAIL: info@getais.com INSURANCE QUOTE: COMMERCIAL INSURANCE BUSINESS OWNER WORKSHEET First Name: Last Name: Business Name: Mailing Address: Mailing City: Mailing State: Select... Alaska Alabama Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming Mailing Zip Code: Phone Number: Fax Number: E-Mail Address: Who Referred You To Our Site? UNDERWRITING INFORMATION Property Address: Property City: Property State: Select... Alaska Alabama Arkansas Arizona California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Iowa Idaho Illinois Indiana Kansas Kentucky Louisiana Massachusetts Maryland Maine Michigan Minnesota Missouri Mississippi Montana North Carolina North Dakota Nebraska New Hampshire New Jersey New Mexico Nevada New York Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Virginia Vermont Washington Wisconsin West Virginia Wyoming Property Zip Code: Property County: Please Describe the Nature of Your Business Number of Owners: Number of Employees: Payroll of Owners: Payroll of Employees: Total Annual Gross Receipts: Total Square Footage of the Building Your Business Is In: Square Footage Of Your Business Only: Current Insurance Company: Business License Number: License Type: Years of Experience: How Many Years Have You Operated This Business: How Many Stories: 1 2 If Two Stories, Ground Floor Square Footage: Total Square Footage of Your Dwelling: Construction Type: Frame Masonry Veneer Masonry Superior Roof Type: Tile Slate Metal Woodshake Composite Material Roof Updated: yes no If Yes, Year Roof was Updated: Protection Distance: 1000 ft or less to a hydrant & 5 mi or less to a fire station Over 1000 ft to a hydrant & 5 mi or less to a fire station Over 5 & up to 10 mi to a fire station Over 10 mi to a fire station Is The Business In A Brush Area? yes no Is This Business Open 24 Hours A Day? yes no Any Deep Frying (Food)? yes no Is There Any Manufacturing, Mixing, Re-Labeling or Repackaging of Products? yes no Is there Filing Of Propane Tanks? yes no Is There Storage More Than 1500 Sq Ft? yes no If An Office Risk, Is E&O With 1 Million Admitted Coverage Carried? yes no Are There Smoke Detectors At This Location? yes no Smoke Alarm: yesno Fire Extinguisher: yesno Deadbolts On All Doors? yesno Circuit Breakers: yes no Electrical Updated: Yes, Updated No Heating - Air Conditioning, Thermostatically Controlled?: yesno Heating - Air Conditioning, Central? yes no Plumbing Updated: yesno If Yes, Year Plumbing was Updated: Interior Automatic Fire Sprinklers: None Partial Full Theft Alarm: None Local Central Fire Alarm: None Local Losses-Claims in the last 5 years: none one two three four five If yes, date, amount paid and description of each loss-claim COVERAGE INFORMATION Building Coverage: Other Structures Coverage: Business Contents Coverage: Loss of Use Coverage: Liability Limits Requested: $100,000 $300,000 $500,000 $1,000,000 Policy Deductible: 100 250 500 750 1000 2500 5000 Questions or Comments to help the Agent: Please press the Submit Button ONCE. Then wait for online confirmation of your request. Thank you for your interest.
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