Property & Casualty Insurance Request For Proposal

Firm Name:                                                                                                [return home]
Contact Name:       
Email Address:       
Address:                
City:                           State    Zip Code
Phone:                        Fax:
Nature of Business:
Number of Locations:   Any outside CA? Yes No
Business Type:       Independent Partnership Corporation Other Please Specify
Location # :
(If more than one location, use an additional RFP below)

Present Carrier:    Policy #:     Annual Premium:
Renewal Date: 
Limits: Building:     Contents: Business Income: 
Other:

Deductible:      
Construction:        Year Built:     #Stores     Total Area:
Sprinkled    Yes No         Burglar Alarm:  Yes No         Central Location?  Yes No

Present Carrier:    Policy #:     Annual Premium:
Renewal Date: 
Limits: General Aggregate:         Each Occurrence:
Fire Damage:                             Medical Expense:
Deductible:      
Annual Receipts:                        Annual Payroll:   
Class Codes Used on Current Policy:    

Present Carrier:    Policy #:     Annual Premium:
Renewal Date: 
Limits: Liability      Uninsured Motorists:     Medical:
Comprehensive Deductible:     Collision Deductible:
Hired Auto Physical Damage? Yes No             Drive Other Car Coverage? Yes No
Number of Vehicles:         Number of Drivers:
Describe how vehicles are used:

Is your Radius greater than 50 miles? Yes No

Present Carrier:    Policy #:     Annual Premium:
Renewal Date: 
Limits of Liability:    Retention Amount: