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Business Insurance Quote
No coverage is bound and no policy is effective until you are contacted by one of our representatives.

Contact Name *
Named Insured *
Mailing Address *
City*, State*, Zip*
Phone Number *
                 Cell:
E-mail Address *
  Website
Effective Date *
       Expiration Date
How did you hear about The McCart Group?
   
     Prior Coverage
 
Do you currently have insurance ? *
Yes No
Current Insurance Company
Policy Number
Premium                                    $
Policy Effective Date
Continuous Coverage in Force Since
Is this carrier Declining, Canceling, or Non-renewing coverage? Yes No
   
     Business Activities
 
Business Type *
Date business was established by current owner
Last year's gross sales/revenue
This year's projected sales/revenue
Describe your normal business activities *
Have you had any losses or claims in the past 5 years? Yes No
If Yes, please provide date of loss, description of loss, and total amount of loss:
 
     Property Information

Premises Address
City, State, Zip
County
Interest Type
Tenant Owner
Is the distance to responding fire station less than 5 miles? Yes No
Is the premises located within the city limits? Yes No
Building Limit
Personal Property Limit
Computer Equipment Limit
Software & Media Limit
Other Limit
Construction Type
Year Built
Total Square Feet of the building?
(All floors excluding Basement)
Total Square Feet you Occupy
Number of Stories
Number of Basements
Any other Occupancies Including Habitational Yes No
If yes, please list
   
 
     If the building is over 15 years old, please answer the following:

Year Roof was Updated
Year Electricity was Updated
Is it on Circuit Breakers
Yes No
Year Plumbing was Updated
Copper or Galvanized Plumbing
     If Other
Year HVAC was Updated
   
     Protective Devices

Less than 1,000 from Hydrant? Yes No
Is Building Sprinklered? Yes No
Fire Alarm Type Central Station Local None
Burglar Alarm Type Central Station Local None
Who is the Service Provider
Smoke Detectors Yes No
   
     Additional Insured

Name of Additional Insured
Address
Phone #
Fax #
Attention
Account or Loan #
Interest
   
     Loss Payee / Mortagee

Name of Interest Holder
Address
Phone #
Fax #
Attention
Loan #
Description of Property
 
     Workers Compensation
 

1
  
Federal Employer ID #
State
Class Code
Classification
Payroll
How many Full Time employees, excluding owners, partners or officers?
How many Part Time employees, excluding owners, partners or officers?
   
2
  
Federal Employer ID #
State
Class Code
Classification
Payroll
How many Full Time employees, excluding owners, partners or officers?
How many Part Time employees, excluding owners, partners or officers?
   
3
  
Federal Employer ID #
State
Class Code
Classification
Payroll
How many Full Time employees, excluding owners, partners or officers?
How many Part Time employees, excluding owners, partners or officers?
   
4
  
Federal Employer ID #
State
Class Code
Classification
Payroll
How many Full Time employees, excluding owners, partners or officers?
How many Part Time employees, excluding owners, partners or officers?

 
Officers / Owners
1
Name
Title
Job Duties
Percentage of Ownership
Payroll (including any bonuses or commissions)
Does the officer/owner wish to be Included or Excluded?
Included Excluded
 
2
Name
Title
Job Duties
Percentage of Ownership
Payroll (including any bonuses or commissions)
Does the officer/owner wish to be Included or Excluded?
Included Excluded
 
3
Name
Title
Job Duties
Percentage of Ownership
Payroll (including any bonuses or commissions)
Does the officer/owner wish to be Included or Excluded?
Included Excluded
 
4
Name
Title
Job Duties
Percentage of Ownership
Payroll (including any bonuses or commissions)
Does the officer/owner wish to be Included or Excluded?
Included Excluded

 
     Comments



   

 

October 2008 Newsletter from The McCart Group
AIG Update - October 1 2008
AIG Security Update, and Additional Thoughts to Consider
September 2008 Newsletter from The McCart Group


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2405 Satellite Blvd - Suite 200 - Duluth, Georgia, 30096 - Telephone: (770) 232-0202 - Fax: (770) 232-9202