Thank you for your interest in AMGIA Insurance

Although the majority of the reqested information below is optional, in order to provide the best service to our clients we ask that you please fill out the requested information as completely as possible.

Before we begin, please answer the following:

Are any additional insureds required? Yes No

Are any special endorsments required? Yes No

Important Policy Information - * required fields

*Name:
	Complete name as it should appear on the policy including Inc., Corp., Ltd., etc.

*Address:
*City:		*County:	*State:	*Zip:

*Main Contact:

*Phone:

Cellular:

Fax:

*Email:

Type of Business

Sole Proprietor

Corporation

Partnership

Other

Policy proposed effective date: e.g. 1/2/2005

Operations - Do not include commas in numbers - e.g. 199000

	Field Payroll	Sales (Current Year)
Automatic sprinkler installation, service, and/or repair	$	$
Dry Chemical / Halon	$	$
Fire Extinguisher servicing, refilling or testing	$	$
Grease Cleaning	$	$
Alarm Installation	$	$
Alarm Monitoring	$	$
Other:	$	$
Retail Sales of Equipment (describe)	$	$

Does the insured use any subcontractors? Yes

Please indicate your % of the following:

Operations:		Client Base:
New Installations	%	Commercial	%
Retrofit/Renovations	%	Institutional	%
Design	%	Industrial	%
Service/Repair	%	Apartments	%
Inspection/Testing	%	Single Family	%
	100%	Condos	%
		Tract Housing	%
		Custom Homes	%
			100%

Indicate Annual Volume Per Construction: Do not include commas in numbers - e.g. 199000

Contract - New Construction:	$
Contract - Retrofit/Renovations:	$
Service/Repair	$
Inspections & Testing	$
Total Sales/ Revenue	$

Does the insured use PVC or CPVC piping? Yes

Total Number of Full Time:

Owners/Officers/Partners:

Field Employees:

Please provide name of current carrier and premium paid. Be sure to provide the loss history for the past year. Do not include commas in numbers - e.g. 199000

Carrier

Premium

Losses

Optional Coverages

Business Auto

Business Personal Property

Umbrella/Excess

Workers' Compensation

Equipment

Licensing

State Portable License Number:
State Systems License Number:
State Sprinkler License Number:
State Alarm License Number:

Verification Code: