Pend Oreille Insurance & Financial Services
Pend Oreille Insurance & Financial Services, Inc.
476394 Hwy 95 N, Ponderay, ID 83852
P.O. Box 967, Ponderay, ID 83852
toll free(800) 392-0762
local (208) 263-2169
fax (208) 255-7318
Office Hours: Mon-Fri, 8-5
GET A QUOTE ON:
Confidence in Insurance Coverage
Financial Services Personal Insurance Services
.

SMALL BUSINESS INSURANCE QUOTATION FORM

To help us supply you with the most accurate quote possible, please answer as many questions
as you can with the most accurate information available to you.

Information submitted will be held confidential and will be used for quote purposes only. Submission of application information in no way obligates you to purchase any product or insurance, nor does it represent any agreement to provide coverage under any insurance policy. Fields with a "*" are required.
BUSINESS INFORMATION
Your name:
 First*:   
Last*:
Name of business DBA:
E-Mail address*:
Address:
City:
State:
Zip code:
Years in business:
Policy period:
 Phone numbers:
Daytime*:
Evening:
Fax:
How would you prefer to be contacted
regarding your quote?
 Phone     Fax     Mail    E-mail
If you would prefer to be contacted by phone,
please let us know the best time to call:
   am   pm
Individual:
Partnership:
Corporation:
Joint venture:
Other:
 
Location Address:
Street:
 
City:
 
State:
 
Zip Code:
Do you have more than one location:
 Yes No
 Interest of premises:
Owner:
Program:
 Retail:
 
Owner/Lessor:
  
 Wholesale:
 
 Service:
  
 Service:
 
 Office:
 
 Office:
 
 Habitational:
  
 Habitational:
Other:
Description of operations:
Mortgagee name & address:
LIMITS OF INSURANCE and OPTIONAL COVERAGES
Building:
Replacement cost:
$
Actual cash value:
$
Construction: Frame
Joisted masonry:
Masonry: Noncombustible:
Fire resistive:
Sq. foot area of each building:
Sq. foot area occupied by applicant:
Year of construction:
Number of stories:
Business personal property:
Do you have more than one building:
 Yes No
Deductible:
Exterior glass: 
Sign: 
Money & Securities
 $10,000 Inside/$2,000 outside:
Systems breakdown / boiler & machinery:
Accounts receivable: 
Valuable papers: 
Business computer: Hardware: 
Software: 
Employee dishonesty: 
Business liability: 
Additional insured name & address: 
Non-owned & hired automobile: 
 Yes No
Annual sales: 
Annual payroll: 
3 YEAR PRIOR CARRIER
Policy #
Expiration date:
Premium:
Policy #
Expiration date:
Premium:
Policy #
Expiration date:
Premium:
LOSS HISTORY
Date of loss:
Loss description:
Amount:
Date of loss:
Loss description:
Amount:
Date of loss:
Loss description:
Amount:
REMARKS