Mathes Insurance Group - Business Package Quotation Form

Business Package
Insurance Quote Form

When filling out the Business Package Insurance Quote Form below, be sure to fill in all of the Information in the RED Sections. If you do not fill out this required information, your form will not be processed.

Mathes Insurance Group is licensed to sell insurance in the State of Iowa. If you are not a resident of the State, or if the exposure you wish to insure is not in the State, we will be unable to provide a quote. Quote indications provided by e-mail from this form are estimates only and are subject to change upon formal application and additional information obtained or revised. Please note that all information submitted will be held confidential except for submission to appropriate insurance carriers and/or representatives for the purpose of obtaining quotes. Mathes Insurance Group accepts no responsibility for electronic piracy, etc., when any information is submitted electronically. Completing and submitting the following information indicates understanding and acceptance of these terms and conditions. Submission of application information in no way obligates you to purchase any product or insurance, nor does it represent any agreement to provide coverage under any insurance policy.

General Information

Name of Business:
Contact Name:
Street Address:
City:	State: ZIP:
County:	Email:
Business Phone:	( )
Fax:	( )
Best time to call:	AM PM

Current Insurance Company (not agency)

Company Name:
Policy Exp. Date:	/ /

What type of coverages do you currently have:
Bond Commercial Auto Commercial Liability Commercial Property	Commercial Umbrella Directors & Officers Liability Disability Group Health	Group Life Professional Liability Workers' Compensation Other

About Your Business:

# of full-time employees	# of part-time employees	How long in business	How many locations	Annual Sales
		yrs.		$

Please give a brief description of your business and clientel:

Please select the type of coverages you want:
Bond Commercial Auto Commercial Liability Commercial Property	Commercial Umbrella Directors & Officers Liability Disability Group Health	Group Life Professional Liability Workers' Compensation Other

Property / Premises Information 1

Street Address:
Owner Tenant	Year Built:	% Occupied
Sprinklers?: Yes No	Construction Type: Frame Concrete Metal
# Stories	#Basements	Sq. Footage
Burglar Alarm: Yes No	Building Value: $	Contents: $
Other Property ( Specify)

Property / Premises Information 2

Street Address:
Owner Tenant	Year Built:	% Occupied
Sprinklers?: Yes No	Construction Type: Frame Concrete Metal
# Stories	#Basements	Sq. Footage
Burglar Alarm: Yes No	Building Value: $	Contents: $
Other Property ( Specify)

Property / Premises Information 3

Street Address:
Owner Tenant	Year Built:	% Occupied
Sprinklers?: Yes No	Construction Type: Frame Concrete Metal
# Stories	#Basements	Sq. Footage
Burglar Alarm: Yes No	Building Value: $	Contents: $
Other Property ( Specify)

Liability

Class of Business:
Contractor / Building Trades	Contractor / Professional Services	Retail
Professional Office	Truckers	Other

Annual Gross Sales (before taxes)

# of employees:

Annualized Payroll:

Cost of any Subcontracted Work:

Limits Requested: $300,000 $500,000 $1,000,000 $2,000,000

Describe any claims you've had in the past 5 years:

Additional Comments:

Please give any additional comments about the coverage you desire:

Thank you for your time in submitting this
Business Package Insurance Quote Form.
One of our representatives will respond to your
submission as soon as possible!

Mathes Insurance Group 120 W. State Street Mason City, Iowa 50401	Phone: 641-423-4663 Toll Free: 877-421-4663
E-Mail: rickmathes@rickmathes.com