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Categories
Information
Personal Lines Insurance
Commercial Prospect Worksheet
General Information
Your Name
(required)
Mailing Address
(required)
Person Calling
Federal ID #
(required)
Telephone
(required)
Fax
Description of Business
General Liability
Annual Receipts
Payroll
Sq.Ft.
Desired / Required Limit of Liability
Additional Insured
Property
Location Address
Construction
Sq.Ft.
Number of Stories
Please make a selection
1
1.5
2
2.5
Bi Level
Tri Level
PC
Building
Personal Property
Year Built
Updates
Electric
No
Yes
Plumbing
No
Yes
Roof
No
Yes
Heating / Cooling
No
Yes
Automobile
Liability Limit
Number of vehicles
0
1
2
3
4
5
6
7
Number of drivers
0
1
2
3
4
5
6
7
Vehicle #1
Year
Make
Model
VIN # (Vehicle Identification Number)
Vehicle #2
Year
Make
Model
VIN # (Vehicle Identification Number)
Vehicle #3
Year
Make
Model
VIN # (Vehicle Identification Number)
Vehicle #4
Year
Make
Model
VIN # (Vehicle Identification Number)
Vehicle #5
Year
Make
Model
VIN # (Vehicle Identification Number)
Drivers
Driver #1
Name
License #
DOB (Date of Birth)
Driver #2
Name
License #
DOB (Date of Birth)
Driver #3
Name
License #
DOB (Date of Birth)
Driver #4
Name
License #
DOB (Date of Birth)
Tickets / Accidents
Please list any tickets and/or accidents
Workers Compensation
Classification / Jobs
Payroll
Officers
Excluded
cforms
contact form by delicious:days
Printed from: http://www.annarbor-insurance.com/prospect-worksheet/ .
© Ann Arbor Insurance Associates, LLC 2012.