Get A Quote - Kapatoes Insurance

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General Information

Complete Legal Name*

First Last

Address

Street Address Address Line 2 City State ZIP Code

Phone*

Email*

Fax

Website

Contact

Years in Business

Package Insurance

Name of current insurance company

Expiration Date

MM slash DD slash YYYY

Building Coverage

Contents Coverage

Square Footage of Space You Occupy

Square Footage of Your Building

Year Built

Number of Stories

If built before 1990, Last Updated

Sprinkler system in building

Yes

Central station alarm

Yes

Refrigeration maintenance agreement

Yes

Does your store do any cooking?

Yes

If yes, is there an ansul system?

Yes

Total estimated annual sales

Total sales of privately labeled/relabeled sales

Total value of point of sale system

Total value of product stored in refrigeration

Liquor Sales

Is alcohol served on premises?

Yes

Is there a restaurant located in the entire building you occupy?

Yes

Are there residential apartments located in your building?

Yes

Are you involved in any other type of business?

Yes

Building Construction

Check one

Frame (walls and roof trusses are wood)

Joisted Masonry (walls brick/concrete, roof trusses are wood)

Masonry non-combustible (walls brick/concrete, roof is metal or non-combustible)

Non-combustible (exterior walls and roof are metal, asbestos, gypsum/other non-combustible material)

Fire-resistive (walls, floor, and roof are constructed of masonry or fire-resistive material)

Umbrella

Yes

Limit

Package Insurance

Name of current insurance company

Expiration Date

MM slash DD slash YYYY

FEIN

Experience Mod

Are you involved in any other type of business?

Yes

Payroll by Class Code

Exec. officers included

Store/8006

Clerical/8810

Other

Claims

No. of property and liability claims in the last 5 years

Amount

No. of workers comp claims in the last 5 years

Amount

Message

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General Information

Package Insurance

Building Construction

Umbrella

Package Insurance

Payroll by Class Code

Claims

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