Treeimage DDR Insurance Service, Inc.

Business Owner's Quote

General Information
Company/Business Name*:
Address Line 1:
Address Line 2:
City:
State:
Zip:
Country:
Phone:
Fax:
Contact Person Information
First Name*:
Middle Initial:
Last Name*:
Day Phone*:
Night Phone:
Best Time to Call:
Email Address*:
Please Tell Us About Your Business
Number of Full Time Employees:
Number of Part Time Employees:
Number of Years in Business:
Number of Business Locations:
Type of Business:
Cost of Any Sub Contracted Work ($):
Annual Gross Sales (Before Tax):
FEIN Number:
Please give a brief description of your business & clientele:
Location 1 Information
Address Line 1:
Address Line 2:
City:
State:
Zip:
Year Built In:
% Occupied:
Building Value:
Contents ($):
Type of Ownership: Owner
Tenant
Construction Type:
Number of Basements:
Area (Sq. Feet):
Burglar Alarm:
Sprinklers:
Location 2 Information
Address Line 1:
Address Line 2:
City:
State:
Zip:
Year Built In:
% Occupied:
Building Value:
Contents ($):
Type of Ownership: Owner
Tenant
Construction Type:
Number of Basements:
Area (Sq. Feet):
Burglar Alarm:
Sprinklers:
Current Insurance Information
Current Insurance Company Name:
Policy Expire Date (MM/DD/YYYY):
Any Losses in Last 3 Years:
Premium Amount:
Years With Current Policy:
Please Provide An Approximate Amount For The Type Of Coverage You Want
Choose The Type of Coverage You Are Looking For: Liability Only
Liability & Business Contents
Liability, Building & Contents Coverage
Miscellaneous Coverage
Liability Coverage (Ex. $300,000, $500,000, $1 Million, etc.):
Building Coverage ($):
Business Content Coverage ($):
Miscellaneous Coverage ($) (All Coverage including Loss of Earnings, Valuable Papers, etc.):
Any additional comments or information that might be helpful in your Business Owners insurance quote:
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DDR Insurance Service, Inc.

Professionalinsurance

223 S Main Street | Jefferson, WI 53549
Phone: 920-674-4996
Fax: 920-674-5169
E-mail: craig@ddr-ins.com

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