Pend Oreille Insurance & Financial Services

		Pend Oreille Insurance & Financial Services, Inc. 325 S. Marion Ave. • Sandpoint, ID 83864 toll free(800) 392-0762 local (208) 263-2169 fax (208) 255-7318 Office Hours: Mon-Fri, 8-5
	GET A QUOTE ON:

Business Insurance Services

Financial Services

Personal Insurance Services

Pend Oreille Mortgage 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.

First Name:
Last Name:
Email:
Address:
City:
State:
Zip:
Day phone:
Evening phone :
Fax:
Contact method:	Phone Fax Mail E-mail
If you would prefer to be contacted by phone, please let us know the best time to call:	a.m. p.m.


Name of Business DBA:
Years in business:
Policy period:
Business type:
Location Address:
City:
State:
Zip:
Do you have more than one location?	Yes No
Interest of premises:
Program:
Description of operations:
Mortgage name & address:
Building:
Replacement cost:
Actual cash value:
Construction type:
Sq. foot area of each building:
Sq. feet of area occuppied 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:
Business computer: 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