Business Insurance Quotation from TC Irons Haines and Haines Insurance

Privacy Policy-We routinely collect personal and/or business information that is needed as part of the quoting and underwriting process. We also collect the same information as part of service and update activities. The Haines & Haines/T.C. Irons Agency will not share that information, or use it in any other way, with outside parties, vendors, etc.

Business Insurance from Haines & Haines/T.C. Irons Insurance

GENERAL BUSINESS INFORMATION

Name of Corp./Business

Business Structure
(Check One) INC CORP LLC
SOLE PROPRIETOR
PARTNERSHIP
OTHER

DBA (if applicable)

Business Address

City

State

Zip Code

Business Web site Address

Ever Filed Bankruptcy or Reorganization? YES NO

Is Business Open 24 Hours? YES NO

Any Manufacturing, Mixing, Re-Labeling
or Repackaging under Own Label? YES NO

Has Coverage Been Declined,
Cancelled or Nonrenewed in Last 3 Years? YES NO

EXPERIENCE & BASIC RATING INFORMATION

Please Describe the
Nature of Your Business

Years of Experience

Years Operating This Business

# of Owners

Annual Gross Receipts

Annual Est. Employee Payroll

LOCATION INFORMATION

Do You Own the Premises/Building? YES NO

Total Sq. Ft. of Building

Total Sq. Ft. Business Occupies

# of Stories

Year Built

Construction Type

Other Construction Type

Roof Type

Other Roof Type

Central Heating & Air Conditioning? YES NO

BUILDING UPDATES

ROOF
(year updated) ELECTRIC
(year updated) HEATING
(year updated) PLUMBING
(year updated)

Yes No Yes No Yes No Yes No

(If yes, year)
(If yes, year)
(If yes, year)
(If yes, year)

BASIC FIRE SAFETY PROTECTION INFORMATION

Distance from Fire Protection (Hydrant)

Distance from Fire Station

Is Your Area A "Brush" Area? YES NO

Is Storage More Than 1500 Sq Ft? YES NO

Is There Smoke Detectors At This Location? YES NO

Is There Smoke Alarm At Location? YES No

Are There Fire Extinguishers? YES NO

Interior Automatic Fire Sprinklers? PARTIAL FULL NONE

Fire Alarm

Theft Alarm

Are There Deadbolts on All Doors? YES NO

COVERAGE REQUEST

CVG. A Building

CVG. B Business Personal Property

Business Income / Loss of Use

DEDUCTIBLE

CVG. C Liability Limits

Losses-Are There Claims in the Last 5 Years? YES No

If Losses and/or Claims
List - Date, Amount Paid and
Description of Each Loss

CURRENT COVERAGE INFORMATION

Current Insurance Carrier

Current Expiration Date

Current Premium

CONTACT INFORMATION
First Name Last Name Email Phone Fax Questions / Comments / Notes
Send my quotation via	E-Mail Fax Regular Mail Call me by Phone!

All quotes are based on the information that the applicant provides, and are subject to change based on final underwriting by the individual carriers.

Our Mission Statement

Dating back from 1872 our mission is clear:

To serve our clients with the utmost respect, integrity and professionalism while providing a comprehensive risk management program at competitive pricing

Policy Coverage
and Disclaimer

Contact

	Haines & Haines/ T.C. Irons
16 West Front Street Florence, NJ 08518 Phone: 609.499.0237 Fax: 609.499.4077	230 High Street PO Box 158- Burlington, NJ 08016 Phone: 609.387.0606 Fax: 609.387.5337	1-3 Bank Street Suite E Medford, NJ 08055 Phone: 609-953-2282 Fax: 609.953.7719
	Wesley Insurance Service Agency 1194 Parkway Avenue Trenton, NJ 08628 Phone: 609.883.4190 Fax: 609.538.0274