Small Business Insurance Inquiry (Pennsylvania Only)

Type of Business: 
Business Name:
Contact Name:
     E-mail: 
Address:
City:
    State:    Zipcode: 
Phone Number:
      Fax: 
What does your business do?

Brief Description of Your Operation:
      Total Annual Sales:     Total Annual Payroll: 
 
Current Insurance: Current Insurance Company: 
Expiration Date of Your Insurance: 
General Business Category
 Institutional / Office / Rental Property / Retail / Service / Wholesale      How Long in Business: 
Ownership in Building:
 Building Owner / Landlord/Lessor / Tenant
Year Building was Constructed:
       Construction:
Frame: exterior wall of wood or other combustible construction, including wood iron-clad, stucco on wood or plaster on combustible supports, or aluminum or plastic siding over frame.
Masonry Veneer: exterior walls of combustible construction veneered with brick or stone.
Masonry Non-Combustible: exterior walls, floors & roof, constructed of masonry materials such as adobe, brick, concrete, gypsum block, hollow concrete block, stone, tile or similar materials.
Fire Resistive: exterior walls and floors and roof constructed of masonry or other fire resistive materials with one or more hour fire rating.
Year of Updates
(if any):
 Wiring:  What was done?        Roof:  What was done?
Heating:  What was done? Plumbing:  What was done?
Fire Protection:
Fire Extinguishers Local Alarm System Only
Hard Wired Smoke Detectors Central Monitored Alarm System
Sprinkler System
Burglar Protection:
Local Alarm Bars & Mesh on Doors & Windows
Central Monitored Alarm System Video Camera System

Coverages
Building:
        $  Deductible
Contents
        $  Deductible
Liability Limit
Outdoor Sign:
Accounts Receivable Records:
Employee Dishonesty Coverage:
# of Employees:

Tenant's Glass Coverage:
 Linear Feet   <---------->
Computer Equipment:
Money & Securities: Inside Premises:
Money & Securities: Outside Premises:

Professional Liability Options
Beauticians Number:  Barbers: Number:  Druggists: Number: 
Funeral Directors: Number:  Opticians: Number:  Veterinarians: Number: 
Printers: Locations:  Optometrists: Number:  Pastorial Liability: Number: 

Insurance Losses
Date of Loss
What Happened......
Amount Paid

Other Information:

M c G R A T H   I N S U R A N C E   G R O U P

4170 William Penn Highway, Murrysville, PA. 15668-1890
(724) 327-8474                 FAX: (724) 327-7911
Toll Free: 1-800-977-2999      Fax: 1-888-800-0034