Wholesaler/Distributor Insurance Quote - FarmerBrown.com - Illinois / Indiana / Chicago Insurance

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WHOLESALER INSURANCE FORM

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Type of Business:	Sole Proprietor Corporation Partnership LLC
Contact Person:*
Phone Number:*	(xxx-xxx-xxxx)
Email Address:*
Address:

City:
State:
Zip:
Number of Stories:
Roof type composition:	shingle tile other
Roof Age:
Automated Sprinkler:	yesno
Manufacturing Product:
Claims in last three years:	yesno
Number of Employees:
Total Payroll:
Bankruptcies or Tax Leins in past 5 years:	yesno
Materials Requiring Special Storage Practices:	yes no
Any Retail Operations:	yes no
Percent of Annual Sales Retail:
Percent of Annual Sales Wholesale:
Retail Operation Location:
Do Customers Purchase Products Via Internet:	yes no
Percentage of Internet Sales:
Does Business Have Peak Season:	yes no
Peak Season Month:
Percentage of Sales During Peak Season:
Specific Program to Withdraw Known or Suspected Defective Products:	yesno
Have your Products been subject to Voluntary Recall:	yesno
Policy Effective Date:
Policy Renewal Date:
Approximate Current Premium:
Current Insurance Carrier: