Texas Insurance Service Center, Inc.| Insurance Services Harlingen, TX

Commercial Form

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Name:*

Address:

Town/City:

State/Province:

Postal/ZIP Code:

Country:*

Email Address:*

Phone:

Fax:

Current Insurance Company

Company Name:

Policy Expiration Date:

Current Insurance Coverages

Current Coverages:

If other:

Business Information

# of Full-Time Employees:

# of Part-Time Employees:

How long in Business? (yrs):

How many locations?:

Please give a brief description of your business and client:

Property/Premises Information

Address:

Occupancy Status:

How many locations?:

Year Built:

% Occupied:

Sprinklers:

Construction Type:

Stories:

# Basements:

Sq. Footage:

Burglar Alarm:

Building Value:

Contents:

Other Property (specify)

Insurance Information

Other :

Annual Gross Sales: (before taxes)

# Number of Employees:

Annualized Payroll:

Cost of any Subcontracted Work:

Limits Requested:

Describe any claims you've had in the past 5 years

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Commercial Form

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