| Fields marked (*) are mandatory. |
| Name of Business* |
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| Address of Business* |
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| City* |
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| State |
VA |
| Zip Code |
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| County |
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| Business Phone |
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| Email |
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| Do you own or lease space in your building? |
Own
Lease
No Locations |
| Describe your business |
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| Number of years in business |
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| Number of full-time employees |
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| Number of part-time employees |
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| Number of commercial insurance claims over the past 5 years: |
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| Do you currently have commercial insurance coverage? |
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| Policy ends on |
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| Coverage Limits |
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| Building Coverage (If necessary) |
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Contents Coverage, If Needed
(equipment, tools, inventory, supplies, etc.) |
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| Liability Limits |
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| Deductible |
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| Miscellaneous Information: |
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| Additional Comments: |
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| Contact Name |
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| Business Type |
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| Are other coverage needed? |
| Workers Compensation |
Yes
No |
| Commercial Auto |
Yes
No |
| Commercial Umbrella |
Yes
No |
|
By submitting this information, I understand that Virginia Insurance Group may contact me via e-mail, phone or fax, using the information I have supplied, to provide quotes or to obtain additional information needed to provide quotes.
Where permitted by law, some insurance companies may confirm your information, through the use of reports which may include driving record and credit score. |