Abram Interstate Insurance Services, Inc.
2211 Plaza Drive, Suite 100, Rocklin, CA 95765
For the most accurate quote please complete the
below form in full.
Phone: 916.780.7000 Fax: 916.780.7181
Commercial Property & Casualty Quick Quote (INDICATION ONLY*)
BROKER INFO Date: _____/_____/____
Agency Name: _______________________________________ Contact: ______________________________
Address: _________________________________City_________________State_______________Zip______
Phone: (___) ____ - ______ Email: ______________________________
● ● ● ● ● ● ● ● ● ● ● ● ● ●
Complete Named Insured: ____________________________________________ Phone: (___) ____ - ______
Doing Business as: _________________________________________________________________________
Mailing Address: _________________________________ City: _______________ State:____ Zip: _________
Location Address: _________________________________ City: _______________ State:____ Zip: ________
Date Business Started: ____/____/_____
Currently Insured: Yes / No Target Premium: _____________
Current/ Prior Carrier: _________________________________________ Expiration Date: ____/____/_______
Claims History: _____________________________________________________________________________
Entity Type: Individual Partnership Corporation LLC Other
Coverage Desired: WC GL PROPERTY AUTO UMBRELLA
Nature of business/ description of operation: ______________________________________________________
___________________________________________________________________________________________
Describe applicant's experience in operations (including # of years): ____________________________________
___________________________________________________________________________________________
# of Employees: __________ Annual Payroll: _______________ Gross Annual Receipts: _______________
Alcohol Receipts: ________________ Business Income: _______________
Additional Insured's Name: _________________________________
Property Information
Building Value: _______________ Contents Value: _______________
Deductible: $500 $1000 $2500 $5000
Building Information
Sprinkler: Yes No Safe: Yes No Theft Alarm: Yes No
Bldg Sq. Feet:
___________Occupied Sq. Footage: __________ Construction Type: ____________
Year Built: ________ # of Floors: ______
Update Year: Roof _______ Plumbing_______ Heating_______ Electrical________
For Bars, Restaurants, Fast Food, and Nightclubs:
1) Major entertainment (DJ, live band, stage show)
? Yes No How many nights per week? ________
2) Is there Danci
ng? Yes
No
3) Is there table seating? Yes
No Table service? Yes No
For Apartments: Annual rental receipts: ____________________________ Number of Units: __________
For Work Comp: Class code: _____________ FEIN____________
For Auto Repair Shops: Desired Garage Keepers Limit: ____________ # of Bays: ___________________
PLEASE EMAIL COMPLETED FORM TO APPS@ABRAMINTERSTATE.COM OR FAX TO 916.780.7181
* Completed ACORD Application and/or Company Supplements required PRIOR to binding.
