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Douglas Insurance Services
PO Box 125, 615 Southt Pike Road
Sarver, Pennsylvania 16055
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Phone: 724-353-1166
Fax: 724-295-0655
Toll Free: 800-722-9990
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Business Owners Package (BOP) & Commercial Insurance Quote
	First & Last Name:
	Business Name:
	Street Address:
	City, State & Zip:
	E-Mail Address:
Telephone:		Fax:
	Current Insurance Information
Insurance Company Name:
Any Losses in last 3 yrs?:
Premium Amount:		Policy Exp. Date:
Describe the Type of Coverage you Currently have:
	About Your Business
# of Full-time	# of Part-time	Yrs. in Business	# of Locations:
Yr. building built	Sprinklered?	Annual Gross Sales	Square Footage?
	Yes No
Building Type:	Masonry Framed Other	Type of Business:	Please select Wholesaler Retailer Manufacturer Contractor Apartment Service
Owned Autos:		Est. payroll / mo.:
How did you hear about us?		Select Referral Internet Search Google Yahoo Bing Flyer/Brochure Phone Book Radio Spot Other
Please describe your business here:
Note: By submitting this form you understand that no coverage is bound until you receive written notice. You also agree to release us from any liability if this information is accidentally viewed by unauthorized persons. We will only use this information for insurance quoting purposes and not distribute to other parties.

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