Dunn & Associates Insurance, Inc.
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Individual Life & Health : Contact


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Commercial/Business Form




General Information
Corporation:     Individual:    Partnership:
Name Insured:  
Phone #:     Fax #: 
Contact Name:  
Phone #:     Fax #:  
Mailing Address:  
City:     State:    Zip: 
Location Address:  
City:     State:    Zip: 
Email Address:  
Type of Business:  
Description of Business:  
Years in Business:     Years Experience:  

Prior Insurance
Prior Carrier:  
Any Losses in Last 3 Years?  

Property Information
How many  buildings/locations?  
Main Building Value:     Contents Value:  
Construction:   Stories:    Sq.Feet: 
Year Built:  
Over 25 yrs, need updates:  
Burgular Alarm?   Y N        UL Certified?   Y N
Type of Alarm:  
Fire Protection:   Sprinklers   Fire Extinguisher:
 Smoke Alarm:   Other:

General Liability
Limit of Liability:      $100,000 $300,000 $500,000 $1,000,000
Rating Info:   Payroll:    Gross/Income: 
If Condo, Motel or Apartments:   # of Units:

Workers Compensation
# of Employees:  
Corporate Officers & Owners:   Included? Excluded?
Please give a job description for each class of employee, and the payroll amount for that class.
Payroll Amount: $ 
Please give a job description for each class of employee, and the payroll amount for that class.
Payroll Amount: $ 
Please give a job description for each class of employee, and the payroll amount for that class.
Payroll Amount: $ 

Miscellaneous
 Please select any of the following in which you may be interested. If you check  the box, please fill out the information that follows.
Glass Coverage:     # Plates: Sq.Feet: Size(inches):
Sign Coverage:     Type: Free Standing: Attached to Building:
Employee Dishonesty           Hired & Non-Owned Autos
Mini-Computer                     Loss of Income

Additional Comments
Please add any additional comments you feel necessary for this quotation. If you have additional information for which there was not enough space above, such as additional drivers, vehicles, driver histories, etc..., please enter here.
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Home :  About :  Staff :  Personal Coverages :  Business Coverages :   Financial Coverages :  Employee Benefits : 
Individual Life & Health : Contact


Dunn & Associates Insurance, Inc.

Phone: (386) 255-2477

324 W. International Speedway Blvd.

Fax: (386) 255-3573

Daytona Beach, FL 32114-4289

Email: info@dunn-insurance.com

© Dunn & Associates Insurance, Inc.