Arkansas HVACR NewsMagazine November 2021

P ROPERTY I NSURANCE Q UOTE F ORM

General Information

Company Name (& DBA):

Mailing Address:

FEIN:

Contact Name:

Years in Business:

Contact Number:

Website Address:

Contact E-Mail:

Property

Physical Address:

Do You Own or Lease Your Building? Own / Lease

Do You Need Coverage On Your Building? Y / N

Contents Coverage Needed:

$10K $25K $50K $100K $150K $200K Other:

Contractors Equipment

Total Value of Tools Under $1,000 Each:

List Any Tools/Equipment Over $1,000 You Want Coverage On:

Description

Year/Make/Model

Serial #

Value

Current/Prior Coverage

Do You Currently Have Insurance Coverage? Y / N

Have You Had Any Prior Insurance Claims? Y / N