Premier Class Insurance Services, Inc.
First Tower Insurance

 

For a prompt, free quote, please complete our online application form.
If you would like to have our agent contact you directly for this information,
please include your name and phone number in lieu of completing this form.

PROPERTY & COMMERCIAL INSURANCE ONLINE QUOTATION FORM

First name:
Last name:
Position:
Organization:
Nature of your business:
Street address:
City:
State/Province:
Zip/Postal code:
Country:
Work Phone:
FAX:
E-mail: (required to process)
Second named insured:
Third named insured:
Other named insured:
Other named insured:
Other named insured:
Proposed Effective Date:
Proposed Expiration Date:
Name of present insurance carrier:

Describe ownership:
(Please check that which applies.)
Individual Partnership Corporation Joint Venture

Other please describe.


Years in business:
Inspection Contact:
Inspection Phone Number:
Accounting Records Contact:
Accounting Records Phone Number:


Premises Information:
Premises 1.
Address:
City/State/Zip:
County:
Interest:
Year Built:
Part Occupied:

Nature of Business/Description of Operations.


Premises Information:
Premises 2.
Address:
City/State/Zip:
County:
Interest:
Year Built:
Part Occupied:

Nature of Business/Description of Operations.


Do you have other locations that we should contact you about?   Yes

COVERAGES
Commercial General Liability Claims Made Occurrence

Deductibles
Property Damage $ Per Claim Per Occurrence


LIMITS:
General Aggregate $
Products & Completed Operations Aggregate   $
Personal & Advertising Injury $
Each Occurrence $
Fire Damage (Any One Fire) $
Medical Expense (Any One Person) $


Other Coverages, Restrictions And/Or Endorsements.


Approximate Annual Gross Income


Schedule of Hazards.


CLAIMS MADE:
Please explain any "Yes" answers below in the "Remarks" section
Has any product, work, accident, or location been excluded,
uninsured or self-insured from any previous coverage?		 Yes   No
Was tail coverage purchased under any previous policy? Yes   No
Remarks


CONTRACTORS:
% of Work Subcontracted: %
Please describe type of work subcontracted:
 
Is Workers' Compensation required? Yes   No
If "Yes", what is the approximate annual payroll?: $
Number of Full Time Staff:
Number of Part Time Staff:
 
Please explain any "Yes" answers below (for past or present operations)
in the "Remarks" section
Does applicant draw plans, designs, or specifications? Yes   No
Do any operations include blasting or utilize or store explosive material? Yes   No
Do any operations include excavating, tunneling, underground work
or earth moving?		 Yes   No
Do your subcontractors carry coverages or limits less than yours? Yes   No
Are subcontractors allowed to work without certificates of insurance? Yes   No
Does applicant lease equipment to others with operators? Yes   No
Remarks


PRODUCTS/COMPLETED OPERATIONS:
Please explain any "Yes" answers below (for any past or present
product or operation) in the "Remarks" section
Does applicant install, service or demonstrate products? Yes   No
Are Foreign products sold, distributed, used as components? Yes   No
Is research and development conducted or new products planned? Yes   No
Guarantees, warranties, hold harmless agreements? Yes   No
Are products related to aircraft/space industry? Yes   No
Have any products been recalled, discontinued, or changed? Yes   No
Are products of others sold or re-packaged under applicant label? Yes   No
Are products under label of others? Yes   No
Is vendors coverage required? Yes   No
Does any named insured sell to other named insureds? Yes   No
Remarks


ADDITIONAL INTERESTS/CERTIFICATE RECIPIENTS:
Additional Insured:   Lienholder:
Loss Payee:   Employee as Lessor:
Mortgagee:      
Name and Address
Reference Number:
Certificate required? Yes   No
Item Description:
Item Location:
Building:
Vehicle:
Boat:
Scheduled Item Number:
Other:


GENERAL INFORMATION:
Please explain any "Yes" answers below (for any past or present
operations) in the "Remarks" section
Any medical facilities provided or medical professionals employed
or contracted?		 Yes   No
Any exposure to radioactive/nuclear materials? Yes   No
Do/have past, present or discontinued operations involve(d) storing,
treating, discharging, applying, disposing, or transporting of hazardous
material (e.g. landfills, wastes, fuel tanks, etc.)?		 Yes   No
Any operations sold, acquired, or discontinued in last 5 years? Yes   No
Machinery or equipment loaned or rented to others? Yes   No
Any watercraft, docks, floats owned, hired or leased? Yes   No
Any parking facilities owned/rented? Yes   No
Is a fee charged for parking? Yes   No
Recreation Facilities provided? Yes   No
Is there a swimming pool on the premises? Yes   No
Sporting or social events sponsored? Yes   No
Any structural alterations contemplated? Yes   No
Any demolition exposure contemplated? Yes   No
Has applicant been active in or is currently active in joint ventures? Yes   No
Do you lease employees to or from other employers? Yes   No
Is there a labor interchange with any other business or subsidiaries? Yes   No
Are day care facilities operated or controlled? Yes   No
Remarks


Other Information and Comments

 

PREMIER CLASS INSURANCE SERVICES, INC.
P.O. Box 7325
Orange, CA 92863-7325

PHONE:   (714) 453-0611
TOLL FREE:   (866) 441-0321
FAX:   (714) 453-0615
E-mail:   info@firsttower.com

CA Lic. #: 0D08422

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