insurance, tax, travel, scooter, moped, motorcycle, car, truck

Business Insurance Application

*Please fill complete application. All fields marked with a are required**
Requested Effective Date	*	Describe of business:
Last Name	*
First Name	*
Address	*	Number of employees:
City	*	Existing insurance:
State	*	If yes, Company name:
Zip Code	*	Policy number:
Telephone	*	Expiration Date:
Fax		Coverage Desired
Email		Liability Limit Desired:
		Professional Liability:	Yes No
Business Name:	*	Personal Property Limit:
Business Type:	*	Deductible:
Business Address:	*	Characteristic of the Insured Premises:
City:	*	Interest:	Rent Own
State:	*	Year built:
County	*	Square Feet:
Zip Code:	*	Number of stories
Year Business Established?	* yyyy	Type of Construction:
		% Occupied:
1	Do the Applicant's Annual Receipts and/or combined building plus personal property values at any one location exceed $3,000,000?		Yes No
2	Do the Applicant's Annual Receipts and/or combined building plus personal property values at any one location exceed $15,000,000?		Yes No
3	At any location, does the Applicant both occupy a portion of the premises and lease 50% or more of the premises (excluding basements) to others?		Yes No
"Optional" If accepted, what methods payment you preferred to pay for the premium.
Payment Type
Name on Account
Account Number
Expiration Date	mm/yyyy
Secure Code	last 3 digits on signature filed (see on back)
Billing Zip Code	type your credit card billing zip code
Terms and Conditions	TERMS AND CONDITIONS Any person who knowingly and with intent to defraud any insurance company or another person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects the person to criminal and subjects the person to criminal and civil penalties. The undersigned is an authorized representative of the applicant and certifies that reasonable enquiry has been made to obtain the answers to questions on the application. He/She certifies that the answers are true, correct and complete to the best of his/her knowledge. I understand that the requested effective date is not indicated that your insurance coverage will be bound but it rather an option. The policy only effective on the date we received payment and signed necessary documents. By typing your name, you have reviewed and agreed to the terms and conditions and also agreed your credit card to be charged additional credit card processing fee 5% by 2K Agency, Inc.
E-Signature	* type your name here