NOMMA Insurance Program Information Sheet

For the fastest and most accurate insurance quote, please provide as much information possible in the form below. This information will be kept confidential and will be used for quote purposes ONLY!

Business Information

Contact Name: Business Name: Email: Website Address: Address: City:   State:    ZIP: County: Phone: ( ) -            Fax: ( ) - # of years in Business: yrs.

Building Location / Property Information

Address: City:   State:    ZIP: Do you Own or Rent?: Own   Rent Year Building Built   Is there an Alarm?: Central   Local   Area Occupied:   Building Square Footage: sq. ft. Building Construction:   Building Value: $ Business Contents Limit:   Percent of Building Sprinklered: % General Liability Limits Desired: $300,000/600,000 $500,000/1,000,000 $1,000,000/1,000,000 $1,000,000/2,000,000 (Per Occurrence / Aggregate)

Business Operations

Please give a Description of Your Operations Below

Accounting Information

Annual Gross Receipts for Shop Work: $   Total Payroll for Shop Work: $ Do you do installation?: Yes     If YES, estimate annual sales: $ Total Payroll for Installaion: $   Federal ID #:

Loss History / Coverages / Current Policy Info

Have there ever been any losses?: Yes   No If YES, please give date of loss(s), description(s), and amount of loss(s).   Other coverages requested: Auto     Workers' Comp.     Umbrella Installation Floater     Equipment Floater   Do you currently have Insurance if Force?: Yes   No     If YES, give expiration date:

Additional Comments

Please give any additional comments about the coverage you desire: