Padgett Insurance Agency PO Box 1119 Richmond Hill, GA 31324
11258 Ford Ave Suite 2 Richmond Hill, GA 31324
Phone: (912) 756 - 6394 Fax: (912) 756 - 2804 Email Us
Fields marked with * are required. When you have completed filling out the form, click the SUBMIT button. All information provided is confidential and will be used solely for the purpose of providing a quote for you. Special features and credits may vary. Applicants are individually underwritten and some businesses may not qualify.
*Your Name:
Title:
*Legal Name of Business:
*Fed-ID-#:
*Phone:
Fax:
*Email:
*Address:
*City:
*State:
Zip:
Currently insured?
Yes
No
If yes, with what company?
Policy expiration date:
If no, reason:
*Nature of Business:
*Years in business:
*# of employees:
*Annual Payroll:
*Annual Sales:
If optical aids or drug store, % of sales due to professional services:
*Check one:
Sole Proprietor
Corporation
Partnership
Home-based
Does the proprietor own/operate any other business? If so, please state:
Has your insurance ever been cancelled or non-renewed? If so, for what reason:
Describe all losses within the last 3 years, whether reimbursed or not. Include date and amount of loss:
County:
Area (square feet):
# of Units:
# of Stories:
Year built:
Building value (if owned):
Value of Business property/equip/furnishings, etc.:
Deductible:
Liability Limit:
Umbrella:
If fire/burglar alarm, what type?
Central Station
Police Dept.
Local
Is the building sprinklered?
Swimming pool on location?
Exterior Walls:
wood frame brick veneer metal panels masonry fireproof walls
Roof:
wood metal panels non-combustible material reinforced concrete asphalt shingles
If over 30 years old, when were the following updated?
Wiring:
Heating:
Plumbing:
Please review your entries for accuracy before submitting your request.
