1061 Dove, Suite 193, Newport Beach CA, 92660
Serving: Arizona, California, & Nevada.
T:800.557.4119 O:949.885.8077 F:949.340.5475
Please include the following:
Renewal/Expiration Date: ________
Current Loss Runs
Current Insurance Declaration Pages or Annual Insurance Disclosure
NAME AND ADDRESS OF BUSINESS: (please print a separate sheet for each location)
How long have you been in business? _________________________
Effective Insurance dates? GL: ____________ Auto: _____________ Work Comp. ___________
Is the Business a Sole Proprietor? Partnership? Corporation? Or L.L.C.?____________________
If business is a Corp, please provide Corp name: _____________________________________
DBA? ___________________________________________________________
Full name of Contact Person? _____________________________________
Phone Number? _______________________________________________
Fax Number? __________________________________________________
Email? _____________________________
F. E. I. N. Number? _____________________________________ License #________________
How many full-time employees? _______________________________
How many part-time employees? _______________________________
ANNUAL PAYROLL FIGURES BROKEN OUT BY CLASSIFICATION CODES (work Comp.):
(Please list all Class Codes below with payroll. If you don’t know Code, give Description
CODE DESCRIPTION ANNUAL PAYROLL # F/P
______ ________________________ ____________________________ ______
______ ________________________ ____________________________ ______
______ ________________________ ____________________________ ______
______ ________________________ ____________________________ ______
______ ________________________ ____________________________ ______
Do you provide Group Medical to Full-Time Employees? _______________
Union Operation? What Union: ______________________________________
www.VisionOneInsurance.com
1601 Dove, Suite 193
Newport Beach, CA 92660
1061 Dove, Suite 193, Newport Beach CA, 92660
Serving: Arizona, California, & Nevada.
T:800.557.4119 O:949.885.8077 F:949.340.5475
Policy Details – (complete if General Liability quote is requested).
Office Location Year Built: _________
Number of Locations: _______ Number of Buildings: ___________
Number of Stories: ______ Fire Sprinkler System: (Yes / No)
Total Building Sq. Footage: ________________ Public Sq. Footage: ______________
Building Amount: ______________ Total Contents Amount? _____________
Liability Limit: _________________ Location Deductible: _____________
Franchise: (Yes / No) Total Receipts: _____________
Roof Type: ______________________________________________
Type of Alarm: ___________________________________________
Permanently Installed Machinery: _______________ Fire Suppression Equip: ________
Describe type of work bidding now: __________________________________________
Any work done over 3 stories? Explain: _______________________________________
Receipts: Estimated Total (complete if General Liability quote is requested).
Current Policy year? ___________________Subcontracted:______________________
Receipts for next 12 months? _____________________ Subcontracted: __________%
Attach 4 years current valued Loss Runs and WCRIB Report (Work Comp.)
Auto Declaration Page with all VIN #’s, Limits and Deductibles
www.VisionOneInsurance.com
1601 Dove, Suite 193
Newport Beach, CA 92660