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A Service of Simons
Insurance Agency
12743 Bellflower Blvd.
Downey, CA 90242
Toll Free: 888-646-2366
Local Phone: 562-803-3101
Fax: 800-346-2245
satisfaction
On-Line Business owners Insurance Quote Form
One Simple Form - takes only 2-3 Minutes!
Your Personal and Company Data
Your Name
Your Company's Name
Street Address
City
State: (Must be California)
Zip Code
E-Mail (REQUIRED)
E-Mail again for accuracy
Phone
Fax (optional)
Currently Insured?
(If yes, list carrier, and # of years
continuous. If none, type NONE)
Type of Business
Retail      Wholesale
Office      Other
List Claims & Amounts Paid
(If none, type NONE)
Years In Business
Business type
(proprietorship, corporation, etc.)
Describe Business in detail
(i.e., Delicatessen and sandwich shop, etc.)
Underwriting Information
Describe IN DETAIL, Your Business Operations
Ownership & Payroll Data
List Employee's Annual Payroll Here
(if none, enter $0)
Insert # of Employees here
Location & Sales Information
Insert Annual Gross Revenues from this operation here
$
Square Footage of office or business location
Type of Building (wood frame, concrete, etc.)
Number of Stories
Are there other business/residences in this building (describe)?
Describe safety features (alarm, sprinklers, fire protection, etc)
Coverage Desired (Check One Please)
The Coverage I Am Looking For:
 
Liability Only
Liability & Business Contents
Liability, Building & Contents Coverage
A Package Policy Including the Above,
        Plus Miscellaneous Coverages
 
NOTE: Don't worry if you are not exactly sure about coverage type... we will suggest the best coverage for you - just try to tell us what you are looking for! (If we need more info. we will let you know.)
 
Liability Coverage:
($300,000, $500,000, $1 Million, etc.)
$
Business Contents Coverage:
(The amount of your personal business property)
$
Building Coverage:
(The amount of building coverage if you own your bldg.)
$
Miscellaneous Coverage:
(List any special coverage peculiar to your business, such as Garagekeepers Legal, Loss of Earnings, Valuable Papers, etc.)
$
Send my quotation via:
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Thank you for filling out this form COMPLETELY!
We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.
Yes, I Agree. Please Send Me a Business Owner's Quote NOW!
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Simons Insurance Agency
CA License #0772640
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