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    On-Line Business & Crime
    Insurance Quote Form
    One Simple Form - takes only 2-3 Minutes!


    Your Personal and Company Data:

    Your Name:
    Your Company's Name:
    Street Address:
    City:
    State: (Must be Florida)
    Zip/Postal:
    E-Mail (REQUIRED):
    E-Mail again for accuracy:
    Phone:
    Fax (optional):
     


    Currently Insured?
    (If yes, list carrier, and # of years
    continuous. If none, type NONE)
     
    Type of Business:
    Retail    Wholesale
    Office    Other
     
    List Claims & Amounts Paid
    (If none, type NONE)
     
    Years In Business:
     
    Business type:
    (proprietorship, corporation, etc.)
     
    Describe Business in detail:
    (i.e., Delicatessen and sandwich shop, etc.)
     
     


     
    Underwriting Information:
     
    Describe IN DETAIL,
    Your Business Operations:
     
    Ownership & Payroll Data:
    List Employee's Annual Payroll Here (if none, enter $0): $ Insert # of
    Employees here:
     
    Location & Sales Information:
    Insert Annual Gross Revenues from this operation here: $ Square Footage of office or business location:
     
    Type of Building (wood frame, concrete, etc.): Number of Stories:
     
    Are there other business/residences in this building (describe)?: Describe safety features (alarm, sprinklers, fire protection, etc):
     
    Coverage Desired: (Check One Please)
    The Coverage I Am Looking For:

    Liability Only
    Liability & Business Contents
    Liability, Building & Contents Coverage
    A Package Policy Including the Above,
            Plus Miscellaneous Coverages

    NOTE: Don't worry if you are not exactly sure about coverage type... we will suggest the best coverage for you - just try to tell us what you are looking for! (If we need more info. we will let you know.)
     
    Liability Coverage:
    ($300,000, $500,000, $1 Million, etc.)
    $
     
    Business Contents Coverage:
    (The amount of your personal business property)
    $
     
    Building Coverage:
    (The amount of building coverage if you own your bldg.)
    $
     
    Miscellaneous Coverage:
    (List any special coverage peculiar to your business, such as Garagekeepers Legal, Loss of Earnings, Valuable Papers, etc.)
    $
     
    Other Coverages You Would Like Information On: Commercial Vehicle
    Bonds, License/Performance
    Workers Compensation
    Builders Risk Insurance Commercial Umbrella
     
     
    Send my quotation via: E-Mail Fax
    Regular Mail
    Please Call by Phone!

     
    Thank you for filling out this form COMPLETELY!

    We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

    Yes, I Agree. Please Send Me a
    Business Quote NOW!

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    Florida Commercial Insurance (An Affiliate of Insurance Office of America)
    4915 West Cypress Street | Tampa, FL 33607 | Phone: 813-262-2303 | Fax: 813-637-8484
    Email: bruce.johnson@ioausa.com | Florida Insurance License #: A132126