passauerandmiller.com
Home
About
Staff
Companies we represent
Insurance & Benefits
Auto Insurance
>
Auto Quote
Business Insurance
>
Business Quote
Employee Benefits
>
Employee Benefits Contact
Home Owners Insurance
>
Homeowner Quote
Medical Insurance
>
Medical Contact
Personal Insurance
>
Personal Insurance contact
Info & Tips
What Our Customers Have to Say
Contact
Business Insurance Quote
No coverage is bound until you receive written confirmation from one of our representatives.
Name
*
First
Last
Business Name
*
Type Of Business
*
Street Address 1
*
Street Address 2
*
Address
*
Line 1
Line 2
City
State
Zip Code
Country
City
*
State
*
Zip
*
Contact Info
Home
*
Work
*
Email Address
*
Business Activities
Type Of Organization
*
Corporation
Individual
Limited Liability Corp
Non - Profit
Partnership
'S' Corporation
1. How many owners , partners ,or officers?
*
2. How many employees , excluding owners ,partners, or officers?
*
3. How many year's have you been in business?
*
4. Last year's payroll:
*
5. This year's projected payroll:
*
6. Last year's gross sales:
*
7. This year's projected sales:
*
8. Describe your normal business activities:
*
Describe your normal business activities
*
Have you had losses or claims in the past 5 years?
*
Yes
No
If yes , please give description ,date and amount paid for each:
*
Please indicate the desired coverage you would like quoted.
*
General Liability
Property
Equipment
Builder's risk
Crime
Worker's Comp
Boiler & Machinery
Garage and Dealers
Remarks
*
Submit
Home
About
Staff
Companies we represent
Insurance & Benefits
Auto Insurance
>
Auto Quote
Business Insurance
>
Business Quote
Employee Benefits
>
Employee Benefits Contact
Home Owners Insurance
>
Homeowner Quote
Medical Insurance
>
Medical Contact
Personal Insurance
>
Personal Insurance contact
Info & Tips
What Our Customers Have to Say
Contact