Commercial / Business Quote Form, Homer Alaska

	509 Sterling Highway, Suite 201 Homer, Alaska 99603 Phone: 907-235-3881 Fax: 907-235-3882
For Commercial Insurance, please complete the information form and our staff will promptly reply.

Please provide the following contact information:

Commercial Insurance Questionnaire

Business Name:

Corporation: Individual Partnership: Other:

Individual Name:
Address:
City:
State:
Zip:
Email:

Physical Address of Business:

Phone (BUS): Phone (Home): Years In BUS:

Business Description

Property Coverage

Year Built: Stories: SQ. FT. Deductible:

Nearest Fire Station: Distance in miles
Nearest fire hydrant (distance)

Values

Building value: Inventory or Equipment:

Sprinkler: Yes Guarded: Yes Burglar Alarm: Yes Other Occupants In Bldg: Yes

Explain all above yes answered

Loss of Income:

Liability

Amount: $500,000.00 $1,000,000.00 Other:

Gross Receipts: Payroll:

hired or non-owned Auto: Yes

Losses: All Lines, Past Five years

SUBMIT YOUR INFORMATION

Please review your entries for accuracy and click the "Submit" button below to send it to us. Use the "Reset" button to clear all your entries from the form.

note: Not a firm quote or binder. Final premium subject to verification of information.

Auto Insurance ◊ Home Owners ◊ Life & Health ◊ General Liability ◊ Charter & Pleasure Boat Ins.
Commercial Auto ◊ Commercial / Business ◊ Surety Bonds ◊ Workers Comp ◊ Home

Questions? email us at Homer Insurance Center