Quote Worksheet

Owners Name:

Phone number:

Full Name of Business:

Email Address:

Corporation:Partnership:Individual:Other

Location Address:

Town:
County:
State:
Zip Code:

Years in Business:
Annual Expected Gross Sales:

Number of Employees:
- Full Time
- Part Time:
Annual Payroll:

Requested Effective Date of Coverage: (note: completion of this form does not bind coverage)

Construction: Frame – combustible material: frame walls with exterior covering e.g. wood, shingles, brick, stuccoJoisted Masonry – masonry materials, e.g. brick cinderblock with combustible floor or roofNon-combustible: masonry materials with metal or other non-combustible floor or roofFire-Resistive: masonry materials with non-combustible floor & roof coated with fire retardant material

Sprinkler System: YesNo
Square Footage you occupy:
Year Built:

Year of Building Updates:
Roof:
Plumbing:
Heating:
Wiring:

Number of Claims in past 3 years:
Describe:

Describe other Tenants in building (i.e. card shop, beauty salon, restaurant):

Building Coverage: YesNo
Limit of Insurance:
Number of Stories:

Business Personal Property Limit of Insurance:
Value of Equipment:

Other Coverage Required:

Do you print Lottery Tickets? YesNo
Improvements & Betterments:

Remarks:

Note: Your proposal will be priced using the information provided above. If you are unable to complete the form at this time, please
obtain the missing information as soon as possible and call or e-mail Ron Rugolo at the following: (631) 650-4014 or
rrugolo@bradley-parker.com when the form is complete. Please note that all leases are different, therefore we suggest you send us a
copy to ensure all insurance requirements are complied with. Completion of this quote worksheet does not bind coverage.

Please leave this field empty.