Max Sadlak Agency, Inc.

Business Quote

General Information
Contact Name *
Email *

Business Name
Business Phone
Current Insurance Company
(not agency)
Company Name
Policy Expiration Date
Current Insurance Coverages
Current Coverages Bond
Commercial Auto
Commercial Liability
Commercial Property
Commercial Umbrella
Directors & Officers Liability
Group Health
Group Life
Professional Liability
Workers' Compensation
Business Information
# of Full-Time Employees
# of Part-Time Employees
How long in Business? (yrs)
How many locations?
Please give a brief description of your business and clientele
Property/Premises Information
Occupancy Status Owner  Tenant
Year Built
% Occupied
Sprinklers Yes  No
Construction Type
# Basements
Sq. Footage
Burglar Alarm Yes  No
Building Value
Other Property (specify)
Insurance Information
Annual Gross Sales: (before taxes)
Number of Employees
Annualized Payroll
Cost of any Subcontracted Work
Limits Requested $300,000
Describe any claims you've had in the past 5 years
Additional Comments
* = Required Field
Disclaimer Notice - The premiums quoted are estimates based on information you provided. This quotation does not constitute a contract of insurance, nor does it provide coverage for any loss or claim. Coverage can only be bound by an agent with a signed application and a down payment.



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