Hruska Insurancenter, Inc

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Retail, Professional and Office Business Questionnaire

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Business Name:

Contact Name:

Phone:
Mailing Address:
Location Address:

City:

State:   Zip:

Ownership:    Individual  Corporation  Non-Profit Corporation  Partnership 
Other:

Building Characteristics:
Construction Type (select):
Frame  Brick  Non-Combustible

Number of Units:
Number of Stories:
Square feet occupied by your operation:
Total approximate square feet of building:
Year Built
.  
Year Updated:  
Roof:
Electric:
Plumbing:
Heating/Air Conditioning:

Type of Electric:
Fuses: 
  Circuit Breakers:

Type of Heating:
Boiler: 
  Gas Forced Air:    Space Heaters: 

Protection Devices:
Smoke Detectors:
  Fire Alarms:   Burglar Alarms:  Sprinklers: Emergency Lighting: 

Please provide a description of the property including any additions or upgrades that should be considered:
   

Underwriting Information
Please provide a detailed description of your operations:
.
.  
Number of Employees:
Total Estimated Annual Sales/Receipts
.  
Current Coverage:  
Building Limit:
Content Limit:
Stock Limit:
Business Income/Interruption Limit:
Electronic Data Processing Limit
computer hardware/software):
Deductible
General Liability Limits:
Professional Liability Limit:
Current Insurance Company:
Expiration Date:
Annual Premium:
Describe any losses over $5000:

Completion of this questionnaire does not afford coverage and is used for quoting purposes only.

Thank you!

 

 
 

Hruska Insurancenter, Inc.
10040 W. 190th Place, Mokena, IL 60448
708-798-5700 Fax 708-798-1475
Toll Free 800-827-5525

 

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