North Star Insurance Services, LLC - Insuring your future

General Information Name of Business: Contact Name: Address: City:   State:   Zip: Phone:   Fax: Email Address: Best Time To Contact You:   AM   PM  How would you like to be contacted?: Phone   Fax   Email   Regular Mail Are you currently insured?: Yes   No Has your insurance ever been cancelled by the insurance carrier?: Yes   No Federal Tax ID#: Please describe your business operations below:

 

Please select the type(s) of insurance that you are interested in: Property    General Liability    Garage Coverage    Automobile    Workers Compensation    Umbrella    Other

Property Coverage Location Address: Location City:   State:   Zip: LIMITS: Building Limit: Computers Limit: Contents Limit: Software Limit: $ $ $ $ Business Income Limit: Tools/Equipment:   Other: $ $     $ BUILDING DETAILS: Year Built: Building Construction: Roof Type: Total Area: # of stories: Basement: Units:

General Liability Coverage Location Address: Location City:   State:   Zip: Description of each type of function/operation at this location: Gross Annual Sales: Annual Payroll: Area/ #units: $ $ $ $ $ $ Do you provide health insurance to your employees?: Yes   No Does your company issue guarantees, warranties or hold harmless agreements?: Yes   No Do you have a commercial auto policy?: Yes   No Does your company install, service or demonstrate any products?: Yes   No Does your company sell any foreign products?: Yes   No Does your company re-package or sell any products of others under your name?: Yes   No Do you draw plans, designs or specifications for other?: Yes   No Do you subcontract work to others?: Yes   No If yes (above), what percentage of your work is subbed out?: %

Garage Coverage If you are interested in Garage Coverage, please email us to discuss further: Email: freequote@thenorthstaragency.com

Automobile Coverage Drivers Name: Date of Birth: Drivers License #: State Licensed: Year: Make/Model: VIN#: Cost New: City Garaged: $ $ $ $ $ Are the vehicles above titled in any name other than the business name?: Yes   No Do you travel in a radius greater than 50 miles from your business?: Yes   No If yes, how far?: Are Motor Vehicle Reports ordered for all drivers prior to hiring?: Yes   No Are any drivers not covered under a workers compensation policy?: Yes   No

Workers' Compensation Coverage Officer Name: Title: Ownership: Include/Exclude*: Salary (if included): Include   Exclude Include   Exclude Include   Exclude *Please note, if excluded, your health insurance may not cover all work related claims. Please list each duty performed: Class code (if known): # of full time employees in this class: # of part time employees in this class: Annual Payroll: Clerical $ Sales $ $ $ $ $ Do you provide health insurance for 75% or more of your employees?: Yes   No Do you have a formal written safety program/manual in place?: Yes   No Federal Tax ID#:

Umbrella Coverage Limit of Insurance: $

Other Coverage If you are interested in Other Coverage, please email us to discuss further: Email: freequote@thenorthstaragency.com

Additional Comments Please give any additional comments you feel appropriate for this quotation. If you have additional information where there was not enough space, please enter them here.

Please click on the "Submit Quote" button to send your quote request.
One of our representatives will respond to your submission as soon as possible.