GAS STATION / LIQUOR STORE / CONVENIENCE STORE QUOTE FORM (Acord 125)

First Name * Last Name * Mailing Address *
Email Address * Phone * Date of birth *
Social Security No. State: * City: *
Zip Code: * Corporation's Name: * What type of Business:
What are your hours of operation: * Do you have your federal ID Number available: *
What is your current insurance company: Expiration Date: Current Premium:
DO YOU HAVE ANY CLAIMS OR LOSSES: (Only if this business HAS OR HAS HAD insurance, REQUEST 3-YEAR LOSS RUNS)
Say: "PLEASE FAX US YOUR 3-YEAR LOSS HISTORY"

PROPERTY SECTION (Acord 140)

How many buildings are on the premises: * How many coverage do you need for building #1: * How many coverage do you need for building #2: *
What is the square footage of building #1: What is the square footage of building #2: How much contents coverage do you need:
Car wash EQUIP. Coverage: How many pumps do you have: How much pumps coverage do you need:
How much canopy coverage do you need: Is your canopy attached to the building:
How much you need Business income Coverage: Crime Coverage: What is your building construction type:
What year was it build: Central Station Alarm :
Sprinkler System:

LIABILITY SECTION (Acord 126)

How much liability coverage do you need: In order to provide you with the best possible quote, please provide the following figures: Gross annual C-Store Sales: $
Gasoline Gallons per year: Beer & Wine Sales: $ Cooking/Deli Sales: $
Annual Car wash Sales: $ Check Cashing Sales: $ If Repair shop, # of Mechanic(s):
Repair shop Sales: $    
NOTES:
*