Maldondo Insurance agency
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Business Name
Legal Entity and DBA
Physical Address
Mailing Address if different than physical
Business Type
Business Entity
Sole Prop
LLC
Corp
Inc
Years in Business
Phone Number
Owner Name
*
First
Last
% of Ownership
Owner Name (copy)
*
First
Last
% of Ownership (copy)
Contact Person
*
First
Last
Website
Email
*
General Liability Current Carrier
Renewal Date
Policy#
Tells us what you know about your current Liability limits or what you wish to be quoted.
# of losses in the past 3 years
Gross Receipts
Personal property coverage amount
# Full Time employees
Date in Sq.
# Part Time employees (copy)
Number of Buildings:
Building/Home Year Built:
No. of Stories:
Sq. Footage:
Type of Construction:
Roof Type:
Sprinklers?
YES
NO
Alarm?
YES
NO
Amount of Insurance:
Deductible Amount $
Checkboxes
Cameras -General
Safety Handbook -General
Safety Meetings -General
Gated Location -General
Gloves (cut/heat) -Restaurant
Shoes (Slip Resistant) -Restaurant
Sprinklers in Kitchen -Restaurant
Fryer -Restaurant
Hard Hats -Construction
Gloves -Construction
Vest -Construction
Lifting Practices -Construction
CA License#
Work Comp Current Carrier
Renewal Date
Policy #
# of losses
Class Code 1
Payroll for class code 1
total payroll amount and hourly rate
Class Code 2 (copy)
Payroll for class code 2 (copy)
total payroll amount and hourly rate
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