Business – Borden Insurance Agency, Inc. | New Bedford, Massachusetts

Are you a current customer?*

Owner Name*

First Last

Nature of business/Description of operations

Type of Entity

Mailing Address

Street Address Address Line 2 City State ZIP Code

Preferred delivery of your free quote*

Phone

Fax

Email*

Covered Property Information

Property Address

Street Address Address Line 2 City State ZIP Code

Do You Own or Lease the location

Type of Building AND Date Purchased

(i.e. Office, Industrial, Apartments)

List Number and Type of Occupants in Building:

Construction Type

# of Sq. Ft. occupied

Your Annual Payroll NOT including Yourself

Year Built

# of Units to be Insured

Building Amount

Business Contents Amount

Loss of Income Amount

Deductible

Liability Amount

Misc. Coverages and Amounts

Underwriting Information

Renewal Date

Current Company

Have you had any losses in the last 5 years

Comments

How did you hear about us

Please specify