Business

Purves & Associates has been insuring businesses in Northern California for over 30 years. Our customers range from your “main street” businesses to non-profits to high-tech type risks. Because we have a broad base of customers we are able to insure all types of risks including General Liability, Workers Compensation and Professional Liability. In order to ensure appropriate coverage, please complete the forms below so that we might better understand your risks and insurance needs.

Required fields are indicated by an asterisk(*).
BUSINESS INSURANCE
GENERAL INFORMATION
DBA:*
Nature of Business*
  For Profit Not for Profit
How long have you been involved in this type of business?
Contact Name*
E-mail Address*
Physical Address *
City*
State*
Zip*
Mailing Address
(if different)
City
State
Zip
Home Phone*
Work Phone
Cell Phone
Current Insurer
(not agency)
Time with your current insurance company
Expiration/Renewal Date
What is your current premium?
Copy of Policy Available? Yes No
# of Full-time Employees
# of Part-time Employees
# of Business Locations (offices)
Annual Sales $
Are you a member of an association specific to your industry?
When was the last time you had a comprehensive review of your insurance?
Other than price, is there any aspect of your current insurance program that you would like to improve?
How did you hear about Purves Insurance?*
Select the coverage you would like us to contact you about: (Check all that apply)
Workers Comp Business Insuranace Business Auto
Professional Liability Employment Practices D & O
Other:
Please fill out the forms below so we can better assist you in your insurance needs.
 
GENERAL LIABILITY & PROPERTY
LOCATION INFORMATION
Owned or Leased** Owned Leased
Square Feet
# of Stories
Year Built
Will you provide us with a copy of your lease? Yes No
BUILDING FEATURES
Roof Type*
If built before 1980, Last year Replaced
Central Heat & AC
If built before 1980, last year replaced
Circuit Breakers
If built before 1980, Last year Replaced
Basement?

sq. feet
Plumbing Type of pipes
Year Updated
Building Sprinklers? Coverage %:
Alarm System?*
Monitored?*
Monitoring Company:
Building Replacement Value
PROPERTY
Furniture & Fixtures: Indoor $ Outdoor $
Machinery & Equipment: $
Stock: $
Property of Others: $
Leased Property: $
Electronic Data & Equipment: Hardware $
Software $
Mobile Equipment (forklifts): $
Tenant Improvements: $
Glass (for Lessee): $
Signs: $
Hazardous Property?

Yes No. If yes, please explain:
 
WORKER'S COMP
Payroll % breakdown
Total # of Employees
Full Time Employees
Part Time Employees
Payment other than Salary
If Yes, Explain
Volunteer Workers
Do you desire coverage for your volunteers?
Hiring Practices (Check all that apply) Drug Testing
Reference Checks
Unions
Pre-Employment Physicals
Other: (explain)
Majority of eligible employees offered Health Insurance?
Management Policies (illness/injury prevention or return to work programs?) explain:
Written Safety Plan
Employee Handbook
OSHA Citations within the past year
Explain:
Losses in the past 5 years?
Explain:
*We will need Loss Runs from your current carrier.
 
BUSINESS AUTO INSURANCE
CAR & DRIVER INFORMATION
Autos Year Make Model Vin # Radius of Use Annual Milage Cost New
Auto 1* miles
Auto 2 miles
Auto 3 miles
Auto 4 miles
Driver Name Date of Birth Sex Marital Status License #
Driver 1*
Driver 2
Driver 3
Driver 4

* Quote subject to favorable driving records of all drivers.
Have you had any accidents in the past 3 years? Please give details.
Questions or Comments?