Seeman Holtz Serves As The Single Source Solution To All Your Business Insurance Needs: High Risk or Hard To Place? No Problem! Specialized Industry Programs We’ll Handle Your Insurance, You Handle Your Business! Get A Quote Today! Request a Commercial Insurance Quote / Service / Consultation Commercial Quote General Information Contact Name: * Age: * Email: * Business Name Address: * City: * State/Province: * Zip/Postal Code: * County * Business Phone: * Fax: * Current Insurance Company (not agency) Company Name Policy Expiration Date Current Insurance Coverages Current Coverages Bond Commercial Auto Commercial Liability Commercial Property Commercial Umbrella Directors & Officers Liability Disability Group Health Group Life Professional Liability Workers' Compensation OtherOther Business Information # of Full-Time Employees # of Part-Time Employees How long in Business? (yrs) How many locations? Please give a brief description of your business and clientele Property/Premises Information Address Occupancy Status Owner Tenant Year Built % Occupied Sprinklers Yes No Construction Type Frame Brick Veneer Stucco Metal Concrete Stories # Basements Sq. Footage Burglar Alarm Yes No Building Value Contents Other Property (specify) Insurance Information Other Annual Gross Sales: (before taxes) Number 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 If you are human, leave this field blank.