Robinson Insurance - Focusing our resources to focus on our clients' business.

 

  Please use this form to apply for a quote. We will respond to your request by the next business day. Thank you!

 
*Indicates a required field.
*Company Name:  
*Street Address:  
*City:      State: TX
*Zipcode:  
 
Company Website:  
Year Founded:  
Federal Tax ID:  
Type of Entity:  
Full-Time Employees:  
Part-Time Employees:  
*Projected Annual Revenues:  
*Projected Annual Payroll:  
Type of Business:  
Description of Business:  
Primary Customers:  
 
 
*First Name:  
Middle Initial:  
*Last Name:  
*Email Address:  
*Business Phone:    Extension
Business Fax:   (ex.999.222.2222)
 
 
Interest in Building:  
Construction Type:  
Year Built:  
Basement?     Yes     No
Sprinklers?     Yes     No
Burglar Alarm Type:  
Square Footage:  
 
 
Building:  
Tenant Improvements:  
Business Personal Property:  
Computer Equipment:  
Loss of Income:  
Extra Expense:  
Valuable Papers and Records:  
Property at Tradeshows:  
Transit Coverage:  
Employee Dishonesty:  
Depositors Forgery:  
Do you have other locations or buildings?     Yes     No
 
 
First Name:  
Last Name:  
Date of Birth:  
Title:  
Percent of Ownership:  
 
 
First Name:  
Last Name:  
Date of Birth:  
Title:  
Percent of Ownership:  
 
There are more owners:  
 
 
Do you have foreign locations?     Yes     No
 
Do employees travel out of state?     Yes     No
 
Do employees travel out of the country?     Yes     No
 
Are there any dependent business premises (e.g. a single location supplier)?     Yes     No
 
Is electronic data processing errors and omissions coverage needed?     Yes     No
 
Do you have franchised locations?     Yes     No
 
Is electronic data processing errors and omissions coverage needed?     Yes     No
 
Do you have high-profile directors?     Yes     No
 
Is directors and officers coverage desired?     Yes     No
 
Is employment practices liability coverage desired?     Yes     No
 
Is boiler and machinery coverage required?     Yes     No
 
Owned autos?     Yes     No
 
If yes, list make, model, VIN, cost new, drivers, birthdates, and driver's licenses:  
 
Are employee health plans provided?     Yes     No
 
Is a 401(k) plan provided?     Yes     No
 
Is an ERISA Bond needed?     Yes     No
 
Is computer fraud coverage needed?     Yes     No
 
Is kidnap and ransom needed?     Yes     No
 
Is life insurance for buy/sell needed?     Yes     No
 
Is key person life needed?     Yes     No
 
Is non-qualified deferred compensation needed?     Yes     No
 
Is workers' compensation needed?     Yes     No
 
Is key person life needed?     Yes     No
 
Are you a subsidiary of another entity or do you have any subsidiaries?     Yes     No
 
Any exposure to flammables, explosives, or chemicals?     Yes     No
 
Do you install, service, or demonstrate products?     Yes     No
 
Are foreign products sold, distributed, or used as components?     Yes     No
 
Do you sell guarantees, warranties, or hold harmless agreements?     Yes     No
 
Are you involved with products related to the aircraft or space industry?     Yes     No
If you answered yes to any of these questions, please explain:  
 
 
Current Insurance Company:  
Expiration Date:  
Who provides your legal assistance?  
Who is your CPA?  
Who do you bank with?  
Who provides your Payroll service?  
   



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