Building/Property Insurance

Name & Address of Business (please submit seperate forms for each location) Required Name & Address of Business (please submit seperate forms for each location) is required.
ZIP / Postal Code Required Input Required Please enter a valid Postal code.
How lond have you been in business? Required How lond have you been in business? is required.
GL Effective Dates Optional
Auto Effective Dates Optional
Work Comp Effective Dates Optional
Type of Business Required Type of Business is required.	select Sole Proprietor Partnership Corporation L.L.C.
If business is a Corporation, please provide Corporation Name Optional
DBA? Optional
First Name Required Input Required
Last Name Required Input Required
Primary Phone Number Required Input Required Please enter a valid phone number
Fax Number Optional
E-Mail Address Required You must provide an e-mail address. A valid e-mail address is required.
F.E.I.N. Number Optional
License Number Optional
How many full-time employees? Required How many full-time employees? is required.
How many part-time employees? Required How many part-time employees? is required.
Type of Alarm Required Type of Alarm is required.
Roof Type Required Roof Type is required.
Annual payroll figures broken out by classification codes
(Please list all Class Codes with payroll. If you don't know Code, give description)
Code or Description Required Code or Description is required.
Annual Payroll and #F/P Required Annual Payroll and #F/P is required.
Code or Description Optional
Annual Payroll and #F/P Optional
Code or Description Optional
Annual Payroll and #F/P Optional
Code or Description Optional
Annual Payroll and #F/P Optional
Code or Description Optional
Annual Payroll and #F/P Optional
Officers and/or Owners
Name / Title Required Name / Title is required.
% of Ownership (must equal 100%) Required % of Ownership (must equal 100%) is required.
Included or Excluded Required Included or Excluded is required.	select Included Excluded
Name / Title Optional
% of Ownership (must equal 100%) Optional
Included or Excluded Optional	select Included Excluded
Do you provide Group Medical to Full-Time Employees? Required Do you provide Group Medical is Required	Yes No
Do you provide Union Operation? Required Do you provide Union Operation? is required.	Yes No
What Union? Optional
Please send 4 years current valued Loss Runs to Vicki@rickrussoinsurance.com
Enter Validation Code Required

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