Voice: 334-792-5101
Fax: 334-792-4552
SLINGLUFF UNITED INSURANCE
P.O. Box 6947
568 South Oates Street
Dothan, Alabama 36301
Office and Business Owner Quote Request

Complete the following information if you would like to obtain a quote. Please understand this is not an application. An application will be sent to you if coverage is desired.

All information provided on this information sheet is confidential and will be used solely for the purpose of developing a quote for you.

Personal Information
First Name:
Last Name:
Business Name:
Street Address:
City:
State:
Zip Code:
Phone Number:
Alternate Telephone:
Fax Number:
Referred By:
Underwriting Information
What is the nature of your business?
Is the business a corporation, partnership, or sole proprietorship? Corporation Partnership
Sole Proprietorship
Number of owners:
Number of Employees:
Payroll of Owners:
Payroll of Employees:
Total annual gross receipts:
Date of Birth:
Years of experience:
Years operated under current name:
Other business names:
Please describe the nature of your business and ANY unusual exposures:
Building & Property Information
Total square footage of the building your business is in:
Total square footage of your business only :
How many stories is it?
If two stories, what is the ground floor square footage?
What is the construction type?
What type of roof covering?:
Was the roof updated?: Yes No
If yes, what year?
What is the distance to fire protection?
Are there smoke detectors at this location? Yes No
Are there fire extinguishers? Yes No
Are there deadbolts on all doors? Yes No
Are there circuit breakers? Yes No
Is the electrical updated? Yes No
Is the heating / air conditioning thermostatically controlled? Yes No
Is the heating/ air conditioning central? Yes No
Has the plumbing been updated? Yes No
If yes, what year was the plumbing updated?
Does the building have interior automatic fire sprinklers? Yes No
Is there a theft alarm? Yes No
Is there a fire alarm? Yes No
Claims Information
Were there any losses or claims in the last 5 years? Yes No
If yes, what is the date, amount paid and description of each loss or claim?
Coverage Information
Current Insurance Company:
How much are you paying now?
What is the liability limit requested?
What is the building limit requested?
What is the building deductible requested?
What is the business personal property (contents) limit requested?
What is the contents deductible requested?
What is the loss of income requested?
Questions or Comments
Best Time To Contact You
Please let us know the best time to call and discuss your quote.    Morning      Afternoon  
   Evening       Anytime
Or Specify Other:
 
2010 slingluffunited, All rights reserved