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Check All Types of Property You Need Covered
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Contents / Furnishings
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Contents / Furnishings Limit Desired
Tenant Improvements & Betterments Limit Desired
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Awning / Canopy Limit Desired
Commercial Auto
How Many Vehicles Need To Be Insured?
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Vehicle #1
Year
Make
Model
Vin #
What Type of Coverage? (Vehicle #1)
Full Coverage
Liability Only
Vehicle #2
Year
Make
Model
Vin #
What Type of Coverage? (Vehicle #2)
Full Coverage
Liability Only
Vehicle #3
Year
Make
Model
Vin #
What Type of Coverage? (Vehicle #3)
Full Coverage
Liability Only
Do You Transport Anyone Other Than Your Centers Children?
No
Yes
Do You Provide Transportation To/From School/Field Trips?
No
Yes
Do You Allow Drivers Under 21 to Transport Children?
No
Yes
How Many Drivers Shall Be Listed?
One
Two
Three
Four
Five
Six
Driver #1
Name
Date of Birth
Drivers License Number
Driver #2
Name
Date of Birth
Drivers License Number
Driver #3
Name
Date of Birth
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Driver #4
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Date of Birth
Drivers License Number
Driver #5
Name
Date of Birth
Drivers License Number
Driver #6
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Date of Birth
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Workers Compensation
How Many Employees Do You Have At One Time?
Provide Annual Payroll for All Employees
Miscellaneous Details
Have There Been Any Claims in the Last 5 Years?
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Yes
Is This a New Venture?
No
Yes
What Insurance Company are You Currently With?
What Is Your Current Annual Premium?
How Did You Hear About Blackwell Insurance Agency?
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