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Business Name

Name

Address

City

ZIP Code

E-mail Address

Phone #
FEIN #

Best Time to Call

Send Quote Via

 E-mail Phone

Years in Business

Current Business Insurance

 Yes  No

If Yes, Current Carrier

Date of Expiration

How did you hear about us

Describe Business Operations

General Liability

Choose Limits of Liability Needed
  Bodily Injury  Property Damage

   Payroll
 # of Employees Weekly Monthly
  

Estimate total Business Income
 Sales or Receipts
 Weekly Monthly Annual
   
 Any losses within the last 36 months?
Description of losses

 
Workers' Compensation coverage needed?

Auto / Truck Coverage

# of Autos # of Trucks # of Trailers
Other

For Business Auto Coverage List  ALL vehicles or fax copy of current policy.
  
Liability Coverage Property Damage
   
Comprehensive Deductible Collision Deductible

Any Contractors Equipment or other Equipment used in business
Any one item valued over $1000 
Provide list or fax current policy with values of each
Property Coverage
1 Building Value Construction Contents
Coverage
Amount		 Type of Contents
2 Building Value  Construction Contents
Coverage
Amount		 Type of Contents

Type of Occupancy or Use of Building

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GEORGE A. ZELLNER COMPANY

INSURANCE
AGENTS, BROKERS & COUNSELORS
SINCE 1921

530 Park Street
Jacksonville, FL 32204

(904) 356-1492

©2006 George A. Zellner Insurance