(503) 582-8902 Canby , OR

Merle Johnson Insurance Agency

Insurance Services for Western & Eastern Oreon

Canby , OR

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Business Quote - Merle Johnson Insurance Agency

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Business Quote - Merle Johnson Insurance Agency

General Information

Contact Name *

Email *

Phone Number *

Type of Business

Business Name

Mailing Address

City

State

Zip/Postal Code*

County

Business Phone

Fax

Current Insurance Company

Company Name

Current Insurance Coverages

Bond

Commercial Auto

Commercial Liability

Commercial Property

Liquor Liability

Directors & Officers Liability

Disability

Group Health

Group Life

Professional Liability

Workers' Compensation

Other

Business Information

# of Full-Time Employees

# of Part-Time Employees

How long in Business? (yrs)

How many locations?

Please give a brief description of your business and clientele

Property/Premises Information

Address

City

State

Zip

Occupancy Status
Owner Tenant

Year Built

% Occupied

Sprinklers
Yes No

Construction Type

Stories

# Basements

Sq. Footage

Burglar Alarm
Yes No

Building Value

Contents

Other Property (specify)

Insurance Information

Business Personal Property Amount

Annual Gross Sales: (before taxes)

If Liquor Liability Required-Gross Annual Liquor Sales?

Annualized Payroll

Cost of any Subcontracted Work

Liability Limits Requested

$300,000

$500,000

$1,000,000

$2,000,000

Describe any claims you've had in the past 5 years

Additional Comments

Note: Coverage Can Not Be Bound Changed Or Deleted Via Electronic Message

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Merle Johnson Insurance Agency | 358 NW 1st | Canby , OR 97032 | (503) 582-8902

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