Ricketson Insurance and Realty Inc. - Business Insurance Proposal Request




	Ricketson Insurance
	and Realty, Inc.

Commercial Lines Questionnaire

Georgia Businesses ONLY

This is a general business questionnaire. We will review the questionnaire before we contact you so we may better understand your business and your insurance needs.

Company:
Name:
Address:
Address:
City:
Zip:		State:
Phone Day:
E-mail Address:		Fax:

Business Information

Type of Business Ownership:
Proposed Effective Date:
Proposed Expiration Date:
Years in Business:
Estimated Yearly Gross Receipts
Estimated Yearly Payroll

Indicate Types of Coverages Applicable

Property
Glass and Sign
Valuable Papers
Crime
Transportation
Equipment Floater
Installation/Builders Risk
Electronic Data
Commercial General Liability
Business Auto
Truckers
Garage and Dealers
Vehicle Schedule
Boiler and Machinery
Workers Compensation
Umbrella

Number of Locations:

Nature of Business (Description of Operations)

Use this area for any special comments or coverages which need special attention.

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