Your Full-Service, Independent Agent:
Let Us Do The Shopping For You.

498 South Ave. Suite A
Tallmadge, OH 44278

330.630.2543 (local)
330.630.2605 (fax)

Toll Free in Ohio
877.630.2500



Important Notice:
Please note that no coverage can be bound using email,
the internet, or by leaving a voice mail message.
Required fields
are in RED
 
Name of Business:
Description of Business:
Mailing Address:
City:
State:
Contact Person:
Phone:
Fax:
Email:
Please check one: Corporation    Individual    Partnership
Location:
(if different from above)

Value of contents:
Business location is: Owned    Rented   
Property Details
Construction: Brick    Frame/Aluminum    Block/Metal   
Square footage:
Year built:
Value of commercial building:
Number of years in business: Number of employees:
Annual payroll: Annual gross receipts:
Garage keeper limit:
(max. value of customer cars on premesis at any one time)
Prior insurance: Yes    No   
If yes, prior company:
Expiring premiums:
Any business losses: Yes    No   
Date of loss:
What happened:
Do you own any other businesses: Yes    No   
Name of other business:
How did you find us: Referral    Google    Postcard    Other  
If referral or other, please describe:
Comments or questions:

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