Texas Business Owner Insurance Form
Business Information
Business Name
Address
City, State, Zip
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
IA
ID
IL
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
PR
RI
SC
SD
TN
TX
UT
VA
VT
WA
WI
WV
WY
Contact Name
Phone No.
Ext
Fax No.
Email Address
Years in Business
Description of Operations or SIC code
Current Insurance Company
Policy Expiration Date
Please quote (check as many boxes as desired)
Owners Insurance
Complete Business Insurance Package
Texas Property Information
Contents (including inventory): $
Square Footage Occupied
Building Limit (if you own the building) $
Type of Construction
Select
Frame (Wood walls & Floors/Roof)
Joisted Masonry (Masonry Walls & Wood Floors/Roof)
Non-Combustible Masonry (Masonry Walls, Non-combustible material floors)
Fire Resistive (Masonry/Concrete Walls, Concrete or Steel Floors/Roof)
Other
Electrical Type
Electrical Renovation Year
Amps
Plumbing Renovation
Select
None
Partial
Complete
Plumbing Renovation Year
Heating Type
Heating Renovation Year
Roofing Renovation
Select
Partial
Complete
Roof Age (years)
Sprinkler system in your building?
Select
Yes
No
Burglar Alarm
Select
Yes
No
Central Station Alarm
Select
Yes
No
Total Annual Sales: $
Is your store located within 5 miles of any coastline?
Select
Yes
No
Liability Information
Select all that apply to your Texas business
Operate or lease aircraft/watercraft
Work Underground
Work above 15 feet Require out of state travel
Use Subcontractors
Delivery Service Pre-employment physicals
Offer safety incentive programs Store, treat, dispose, or transport hazardour waste Work on vessels, docks, or bridges over water
Other
General Aggregate Limit (other than products completed)
Select
$300,000/$300,000
$300,000/$600,000
$500,000/$1 million
$1 million/$2 million
Other Amount
Products/Completed Operations Aggregate Limit
Select
$300,000/$300,000
$300,000/$600,000
$500,000/$1 million
$1 million/$2 million
Other Amount
Texas Workers Compensation Information
Umbrella Insurance Amount Desired
Select
None
$1 million
$2 million
$5 million
Experience Mod (if any, per policy)
Federal Employer's ID #
Additional Information
I accept the terms
Submit Request
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