Office Package Insurance Questionnaire
Insured Name:
Address:
City:
County:
State:
Zip Code:
If property address is different from mailing address, please provide additional infromation:
Phone:
Email:
Current Insurance Company:
Expiration Date:
Annual Gross Receipts:
Building Replacement Cost Value:
Business Personal Property Replacement Cost Value:
Computer Hardware and Software Value:
Valuable Papers Limit:
Value of Property away from your office
( i.e. field equipment ):
Are you interested in quotations on the following additional coverages?
Hired Car Physical Damage Coverage: Yes
No
Employee Benefits Liability: Yes
No
Foreign Travel Yes
No
Number of trips per year
Destinations
Commercial Umbrella Liability Coverage: Yes
No
Coverage for your interest in a joint venture: Yes
No

Square footage of your office area:

Square footage of building:
Year Building built:
Number of stories:
If your building is more than 30 years old, specify year of building improvements (wiring, heating, plumbing, roof, etc):

Select the construction type of your building:

Frame
Masonry Non-Combustible
Joisted Masonry
Modified Fire Resistive
Non-Combustible
Fire Resistive
 


 
 
Submitting this form does not bind the insurance company or agency to sell nor the applicant to purchase the insurance.		  
 

Euclid Insurance I 234 Spring Lake Drive I Itasca, IL 60143 I Phone: 630-694-3700 (ask for a member of the A/E Team) I Fax: 630-773-4075 I E-Mail: ae@euclidinsurance.com
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