BUSINESS INSURANCE FORM

Please take five minutes of your time to find how much you can save.
 It is understood that this is not an application for insurance.
 There is no obligation and no sales person will call or visit me.
 

 GENERAL BUSINESS  INFORMATION
 Business Name:
 Contact Name:  
 Mailing Address:  
 City / State / Zip:    
 Work Phone / ext: Cell Phone:   
 Fax:    
 E-mail Address:
 Years In Business:
 
 PROPERTY INFORMATION
 Description of Business:  
 
 Number of Stories: Year Built:
 Square Footage: Other Occupancy:
 Number of Units:    
 Seasonal Business: Gross or Annual Sales:
 Construction of Building:  
       
 UPDATING DATES (Enter Date)      
 Roof: Plumbing:
 Electric    
 Heating: Heat Type:
 Smoke Detectors: What Kind of Smoke Detectors?
 Burglar Alarm What Kind of Burglar Alarms?
 Fire Sprinklers    
 
 CURRENT INSURANCE
 Current Insurance Company:
 Current Premiums:
 Expiration Date:    
       
 NEW POLICY REQUEST (Enter requested limits)
 Building Limit? $ Contents Limit? $
 Computer Limit? $ Business Income Limit? $
 Current Wind Deductible? $ Other Property Deductible? $
 Liability Limit? $ Liability Limit? $
       
 CLAIMS HISTORY
 Date of Loss Amount Paid Description
 
 
 
 
 
     
 FAIR CREDIT STATEMENT


Note: You must agree to the following terms in order to use this service.
Please read the statement below, carefully - before proceeding.

 

I understand that the Coastline Insurance Agency, INC. on behalf of the Insurance Company will order an investigative consumer report as part of the underwriting process to qualify, evaluate, and quote my insurance coverage. Various consumer reports such as motor vehicle reports, credit reports, and claim history with prior insurance companies, may be obtained. In the event that the coverage is denied based on information in one of these reports, I will be advised of this and given the name and address of the consumer agency making the report.


Please note: The price estimate (or quote for insurance coverage) provided to you by the Coastline Insurance Agency, INC. will be base on the information supplied by you on this application.


I Have Read the "Fair Credit Statement - and I AGREE to the terms set forth.

WARNING: Do NOT Continue without checking the box above.
You will not be able to continue and the answers to the questions you just answered may be lost




 

 



 Coastline Insurance Agency Inc.
 1201 New Jersey Avenue
 North Wildwood, New Jersey 08260
Phone: 609-522-4515  
Fax: 609-522-9174  
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