Home Business Insurance workstation Home Business Insurance

For California Residents only.

After you've completed this form, click on the SUBMIT button to receive your free Home Business Insurance quote. You'll be given an opportunity to specify U.S. Postal Service, e-mail or fax. Or phone (760) 644-0351.
Customer Information
Business Type
Business Name
Name of Applicant
E-mail
Location address
City
State
Zip Code
Home Phone
Work Phone
FAX

THE FOLLOWING ARE GUIDELINES FOR THIS IN-HOME BUSINESS PROGRAM:

PROFESSIONAL LIABILITY IS EXCLUDED ON ALL CLASSES

MEDICAL PAYMENTS OF $5,000 EACH PERSON INCLUDED  (under liability coverages)

STANDARD DEDUCTIBLE IS $100  (no other deductible available)

Mailing Address (if different than Location Address):
Mailing Address
City
State
ZipCode

Operations Description
Applicant is : Individual   Partnership   Corporation   Joint Venture
Interest in Premises Own       Rent
Dwelling Occupancy Single   Multiple
Dwelling Construction Frame   Masonry
Years in Business
Business Description
(in 10 words or MORE)
Additional Insured
Address of Additional Insured
City
State
ZipCode

Limits / Coverages Requested
Business Personal Property
General Liability
Electronic Data Equipment
Money & Securities
(On/Off Premises)		 $1,000/$1,000   $2,000/$1,000   $3,000/$1,000  
$4,000/$1,000   $5,000/$2,000   $7,500/$2,000   $10,000/$5,000  

General Underwriting Information :
(If any question is answered YES or is not answered, you will not be eligible for coverage.)
Yes  No   1.  Is your business based in an area other than your residence
        (residence includes outbuildings within 100 feet)?
Yes  No   2.  Have you had more than two claims of any type, related to your
        Business operation, in the last three years?
Yes  No   3.  Have you had a single claim, related to your business, for more
        than $25,000 in the past three years?
Yes  No   4.  Do you own any business under the same legal name as the "Business Name"
       shown, which is permanently operated from a second location??
Yes  No   5.  Do you repackage food or personal care products to be sold under your own label?
Yes  No   6.  Are you involved in the sale or manufacturing of explosives or propellants
        and/or use of flammable liquids?
Yes  No   7.  Do you install any products, excluding the installation of computer systems,
        office equipment, security devices or draperies?
Yes  No   8.  Is your business operated by someone other than yourself and/or another
        immediate family member who resides in your household?
Yes  No   9.  Did your gross annual sales/receipts from your business pursuits for the
        most recent calendar year exceed $250,000 for sale of merchandise or
        $500,000 for service business?
Yes  No 10.  Do you employ more than ten (10) employees, other than independent
        contractors or distributors?
Yes  No 11.  Is your dwelling located within 1,500 feet from the seacoast on the
        Gulf of Mexico or the Atlantic Ocean?
Yes  No 12.  If you are a teacher or tutor (rather than a personal fitness trainer), do you
        provide instruction for sports, physical education, industrial arts, or martial arts?

Questions, Remarks and Comments:

Reporting Method
How would you like to receive
your free Home Business Insurance quote?		 U.S.Postal E-mail Fax Phone

 

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