Your Independent Erie Agent for Auto - Home - Business - Life

 

 

Business Insurance Information Form:

Use this form to receive information about Insurance for your business.
   Please type in the ID Number, below, exactly as it appears here:  mt01
* = Required ID Number :*
  Your Name:*
  Your Phone Number:*
  Your E-Mail Address:*
  Your Street Address:
  Your City
  Your State:
  Your Zip:
  Type of Business:
  Number or Employees:
  Yes No Commercial Property/Casualty
      1. Is the business a: (Check One)
      Sole Proprietorship Corporation Partnership
  2. Does the business own the building(s) it occupies?
  3. Does the business rent out any part of the building(s)?
  4. Does the business have a peak season?
  5. Would you like to increase your deductible?
  6. Would you like to increase your limits of liability?
  7. Do you have tools or equipment that you take off your premises?
  8. Do you hire subcontractors?
  9. Would you like to purchase Business Income Protection?
  10. Would you like to purchase Rental Income Protection?
  11. Would you like to purchase Extra Expense Coverage?
  12. Would you like to purchase Building Ordinance or Law Coverage?
  13. Wouldyou like to purchase Contingent Business Interruption Coverage?
  14. Would you like to purchase Sign Coverage?
  15. Would you like to purchase Glass & Lettering Coverage?
  16. Would you like to purchase Professional Liability Coverage?
  17. Would you like to purchase Voluntary Property Damage Coverage?
  18. Would you like to purchase Employee Dishonesty Coverage?
  19. Would you like to purchase Employee Benefits Liability Coverage?
  20. Would you like to purchase Sexual Harassment/Employment Practices Coverage?
  21. Would you like to purchase Fellow Employee Liability?
  22. Would you like to purchase Directors and Officers Liability Coverage?
  23. Would you like to purchase a Business Catastrophe Liability?
  24. Would you like to purchase Earthquake Coverage?
  25. Would you like to purchase Sewer and Drain Back Up Coverage?
  26. Would you like to purchase Mechanical and Electrical Breakdown Coverage?
  27. Would you like to purchase ERISA Coverage?
  28. Would you like to purchase Liquor Liability Coverage?
  29. Would you like to purchase Flood Coverage?
  30. Does your business have need for surety bonds?
  31. Would you like to purchase group coverage for health insurance?
  32. Would you like to purchase group coverage for life insurance?
  Yes No
Commercial Auto
  1. Does the business own any autos?
 
If yes, would you like to purchase coverage for these autos?
  2. Would you like to purchase coverage for autos owned by executive officers or partners of the business?
  3. Do any employees use their autos in your business?
 
If yes, would you like to purchase coverage for this exposure?
  4. Do you hire, rent or borrow any autos in your business?
 
If yes, would you like to purchase physical damage and/or liability coverage for these autos?
  5. If the business is a dealership, would you like to purchase coverage for dealer's errors and omissions and/or title errors and omissions?
  6. If the business is a dealership, would you like to purchase false pretense coverage?
  7. Do we have your most current list of drivers?
  Send us any additional information:
   
Mays Tucker Insurance
Suite 102, 1744 S. Amherst Highway
Amherst, VA 24521-3369
434-946-2131
434-263-8120
Fax: 434-946-9242
Email: maystucker@msn.com

© Copyright 2002 Mays Tucker Insurance. All rights reserved.