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Our Business Insurance Carriers

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Arizona Business Insurance Application

Pritchard Group Insurance makes shopping for business insurance easy. Fill out our short, easy form and we'll shop for those companies who will compete for your business and find you the best deal. Get started now.

Business Name:	*
DBA:
Owner / Contact:	*
Street Address / Suite:	*
City / State / ZIP:	*
Phone (please include area code):	*
Email:	*
Type of Organization:	--Select-- Corporation LLC Sole Proprietorship Partnership Other
Number of Full Time Employees:	--Select-- 0 1 2-3 4-5 6-10 11-20 Over 20
Number of Part Time Employees:	--Select-- 0 1 2-3 4-5 6-10 11-20 Over 20
Type of Business:	--Select-- Professional Services Retail Store Automotive Repairs Personal Services Home-Based Business Other
Hours of Operation:	--Select-- Less than 40 hours per week 41 - 50 hours per week 51 - 60 hours per week 61 - 70 hours per week 71 - 80 hours per week More than 80 hours
Years in Business:	--Select-- Less than 1 Year 1-2 Years 2-4 Years 4-6 Years 6-8 Years 8-10 Years Over 10 Years
Gross Sales - $		Yearly Payroll Excluding Owners - $

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General Liability Information

Will this replace an existing business policy?	YES NO
Current Carrier
When will your current policy expire?	--Select-- Jan Feb Mar Apr May June July Aug Sep Oct Nov Dec --Select-- 2009 2010 2011 2012 2013
Liability Limit:	--Select-- $300,000 $500,000 $750,000 $1,000,000
Losses in last 3 Years - $
Current Yearly Premium - $
Has your coverage ever been canceled?	YES NO

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Property & Contents Information

Is your building ...	LEASED OWNED
Name of Landlord / Mortgage Holder:
Burglar Alarm?	YES NO
Sprinklers?	YES NO
Fire Alarm?	YES NO
Year Built:
Type of Construction
Business Personal property Limit - $
Business Personal Property Deductible - $
Contents Value - $
Value of fixtures and Displays (not part of building) - $

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